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The

Aligning practice with policy to improve patient care

Volume 3, Issue 2

How to Thrive in
Back to Basics: a Tough Economy
Electrosurgery

Surgical Site Infections:


Are you playing your
part in prevention?
5 Pressure
Ulcer
Factors
to Keep
FREE CE PAGE 22 in Mind
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The

OR Connection
Aligning practice with policy to improve patient care

Sue MacInnes, RD, LD


Editor
PATIENT SAFETY
16 Back to Basics: Electrocautery Safety and OR Fire Prevention
Alecia Cooper, RN, BS, MBA, CNOR
Clinical Editor

24 Left Behind
Andy J. Mills, MBA, MWM
Contributing Editor
30 World Health Organization Issues Safety Checklist for
Surgical Teams
Mike Gotti
Art Director
37 Surgical Site Infections
Laura Kuhn
Copy Editor
43 Flipping the Switch on Pressure
46 Five Pressure Ulcer Factors to Keep in Mind Page 13

Jayne Barkman, RN, BSN, CNOR


Clinical Team

Rhonda J. Frick, RN, CNOR OR ISSUES


Anita Gill, RN 40 Great Ideas from Your Peers: Surgical Skin Prep Solutions
Megan Giovinco, RN, CNOR, RNFA
Kimberly Haines, RN, Certified OR Nurse 50 The History of the Surgical Technologist
Jeanne Jones, RNFA, LNC
Carla Nitz, RN, BSN SPECIAL FEATURES
Connie Sackett, RN, Nurse Consultant 5 Letters from Our Readers
Claudia Sanders, RN, CFA
Angel Trichak, RN, BSN, CNOR
13 SCIP’s Role in the CMS 9th Scope of Work Proposal Page 16

32 Moments of Truth
Gail Avigne, RN
Perioperative Advisory Board
54 A Place of Healing?
Shands Teaching Hospital (UFL), Florida
Caroline Copeland, RN MPH
58 Callie Craig: A Nurse Hero
Southern Hills Hospital & Medical Center 62 How to Thrive in a Tough Economy
Cathy Crandall, RN
HealthTrust Purchasing Organization, Tennessee
68 Angel’s Passion for Pink
Larry Creech, RN, MBA, CDT
71 Medline Supports Breast Cancer Awareness
Carilion Health System, Virginia 73 Recipe: Guacamole Page 24
Pat DʼErrico, RN, CNOR
Medical Center of Central Georgia, Georgia CARING FOR YOURSELF
Barbara Fahey, RN CNOR
Cleveland Clinic, Ohio
61 Building Unshakable Self-Confidence
Zaida Jacoby, RN, MA, M.Ed 72 Ease the Discomfort of PMS
NYU Medical Center, New York
Sherron Kurtz, RN, MSA, MSN, CNOR, CNAA FORMS & TOOLS
Wellstar Kennestone Hospital, Georgia 76 Electrosurgery Checklist
Wayne Malone, RN
Physicians Hospital, Texas
78 Electrosurgical Cautery Safety Page 32

Lynda Mansfield, RN, CNOR 81 Pressure Ulcer Prevention


Orange County Memorial, California
86 Surgical Safety Checklist
Jackie Minor, RN CNOR
Huntsville Hospital, Alabama
89 Checklist: Organizational Assessment Questions Regarding
Jennifer Misajet, BSN, MHA, CNOR Management Commitment to Employee Involvement
Exempla St. Joseph Hospital, Colorado
90 Confidential Incident Report
Pricilla Ranseur, RN, MSN, CNOR
Duke University Hospital, North Carolina
Margie Voyles, RN, MS, CNOR
Lakeland Regional Medical Center, Florida
Page 62

Margery Woll, RN, MSN, CNOR


Rush North Shore, Illinois

Aligning practice with policy to improve patient care 3


THE OR CONNECTION I Letter from the Editor

Dear Reader,
Everyone agrees that preventing hospital- Then go to Page 86 in the Forms & Tools section,
acquired conditions can save thousands of lives where you can tear out a copy of the checklists for
and millions of dollars. This is the time to take your own use.
action. Hospitals across the country are implement-
ing new strategies. All of us are feeling the swell of But even with your checklist in hand, it might not be
change and the push back that comes with it. enough. That is why you should read through
Whether you are working with administration, mate- “Moments of Truth: How to enact a culture change at
rials management, your staff, physicians, vendors, your facility.” There are no miracles here, but a keen
consultants or your peers, the journey isnʼt and wonʼt understanding and expert guidance on how to create
be easy. Iʼve spoken to thousands of clinicians about a team that works together, problem-solves together,
the barriers they are facing when it comes to imple- helps each other out to give the patient the best
menting new policies and improving safety, quality care possible.
and patient satisfaction. Everyone wants to do
whatʼs right. The overwhelming things that we need Each of us contributes to the culture we work in, so
to make that happen are teamwork, communication,
education and – in many cases – additional
I was thrilled with Wolfe Rinkeʼs article “How to
Thrive in A Tough Economy” (Page 62). This article

This edition of
The OR Connection
resources. takes a closer look at how you can positively affect
is about bringing
your organization and your career in these times. positive change
This edition of The OR Connection is about bringing
positive change into your facility. One key solution Last, but certainly not least, this edition is chock-full
into your facility.”

that can help your patients receive a higher standard of safety updates and information. Thank you for
of care is the use of a checklist. I know if something being a part of the team. We look forward to visiting
is not on my list, there is a chance it will be forgotten. with you again in our next edition.
With the day-to-day pressure, interruptions and
stress that each of you must deal with in the OR, a Sincerely,
checklist might be just the right calming factor.
Checklists act as reminders to keep us on track, to
make sure weʼve covered everything we need to do. Sue MacInnes, RD, LD
Youʼll want to take a look at Page 30, where you will Editor
find the “Safety Checklist for Surgical Teams.” There
are three recommended checklists:

1. Before anesthesia is induced


2. Before skin incision
3. Before the patient leaves the operating room

We've coded the articles and information in this magazine to indicate which patient
Content Key

care initiatives they pertain to. Throughout the publication, when you see these
icons you'll know immediately that the subject matter on that page relates to one
or more of the following national initiatives:
• IHI's 5 Million Lives Campaign
• Joint Commission 2007 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)

We've tried to include content that clarifies the initiatives or gives you ideas and
tools for implementing their recommendations. For a summary of each of the above
initiatives, see pages 6 and 7.

4 The OR Connection
You Said It!

Letters from Our Readers


I really enjoy The OR Connection and find the articles to be fresh ideas and articles to share with my staff that is relevant
interesting, current and evidence-based. I look forward to the and easy to understand. I just signed up for a subscription for
new issues and have been able to implement some of the our OR dept and want to thank you. I think the crosswords
tools as teaching aids. Thank you very much for a publication and word search are fun and informative.
specifically for the OR which puts policy and practice together
– Sara Smith, RN, CNOR
to improve patient care and safety.

– Maureen Bollin, RN, CNOR, Perioperative Educator I wanted to pass along a thank you for The OR Connection
magazine you dropped off. I really enjoy reading them. There
As an educator, I was pleased with the timeliness of the is a lot of valuable information in it that I pass along to others.
articles, the activities for the staff and their presentation. The I get a lot of magazines in the mail and I must say this is one
topics are pertinent, and easy to read. I love the variety to of the few I review cover to cover and pass on to others.
articles. I am only sorry I don't have all your issues. This Medline does a nice job with this. Thanks again!
magazine is a great resource tool, and when your staff needs
– Janna Petersen, RN
an in-service, there is always something to draw on. Thank
you for publishing it, I hope it continues.
I love your magazine, keep up the good work!
– K. Smith
– Lynne Arnaut
This type of project is so very valuable to clinicians and
The Back to Basics series has become a hit at our two
establishes your clinical credibility that is a major differentiator in
facilities….I had been working hard on getting staff to read
the market today. Kudos to you and to your clinical team.
your great issues of The OR Connection and now it looks
– Sandy Wise, RN, MBA like it has finally happened.

– Sophia Schild
I received this issue at AORN Congress this year in
Orlando. What a GREAT magazine this is!!! It incorporates
Great issue of The OR Connection! I am just amazed at the
so many of today's issues affecting perioperative care. The
content, information, format, etc. You do have a gift for this
education is invaluable. Thank you!
publication series.
– Rose Trojkovich
– Nancy B. Bjerke, RN, MPH, CIC
I recently got to read Volume 2, Issue 1 given to me by a
fellow OR nurse and I really enjoyed the great reading and Has The OR Connection been helpful at your facility? Is
love the format. I plan on using this info in education of the OR there a topic youʼd love to see us tackle? Drop us a line at
staff in my facility. As an educator I am always looking for orconnection@medline.com. Weʼd love to hear from you!

Aligning practice with policy to improve patient care 5


Three Important National Initiatives
for Improving Patient Care
Achieving better outcomes starts with an understanding of current
patient-care initiatives. Here’s what you need to know about national
projects and policies that are driving changes in care.

1 5 Million Lives Campaign


Origin: Launched by the Institute for Healthcare Improvement (IHI) in December of 2006
Purpose: To prevent unintended physical injury resulting from or contributed to by medical care that requires
additional monitoring, treatment or hospitalization, or that results in death
Goal: To prevent five million incidents of medical harm over the next two years and to enroll more than
4,000 hospitals and their communities in the project.

Hospitals sign up through IHI and can choose to implement some or all of the recommended changes. IHI provides how-to guides
and tools for data measurement and submission. IHI tracks Acute Care Inpatient Mortality rates for all participating hospitals.

The new campaign incorporates the six original planks from the 100,000 Lives Campaign and adds six additional planks to prevent harm.

2 Joint Commission 2008 National Patient Safety Goals


Origin: Developed by Joint Commission staff and a Sentinel Event Advisory Group
Purpose: To promote specific improvements in patient safety, particularly in problematic areas

Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission
offers guidance to help organizations meet goal requirements.

This yearʼs new requirements have a one-year phase-in period that includes defined expectations for planning,
development and testing (“milestones”) at 3, 6 and 9 months in 2008, with the expectation of full implementation
by January 2009.

3 Surgical Care Improvement Project (SCIP)


Origin: Initiated in 2003 as a national partnership. Steering committee includes the following
organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the
Joint Commission
Purpose: To improve patient safety by reducing postoperative complications
Goal: To reduce nationally by 25 percent the incidence of surgical complications by 2010

SCIP aims to reduce surgical complications in four target areas. Participating hospitals collect data on specific process and
outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical
complications annually (just in Medicare patients) by getting performance up to benchmark levels.

6 The OR Connection
Patient Safety

5 Million Lives Campaign: Twelve Interventions


1. Prevent pressure ulcers 9. Deliver evidence–based care for acute
2. Reduce methicillin-resistant staphylococcus myocardial infarction
aureus (MRSA) infection 10.Prevent surgical-site infections
3. Prevent harm from high-alert medications 11. Prevent central-line infections
4. Reduce surgical complications 12.Prevent ventilator-associated pneumonia
5. Deliver evidence-based care for congestive heart failure
By the numbers:
6. Get boards on board
• 3,954 hospitals currently enrolled
7. Deploy rapid response teams
• The Top 3 Interventions:
8. Prevent adverse drug events (ADEs)
1. Adverse Drug Events (ADEs) – 3,010
• An IHI forum, “Celebrating 20 Years: The Future 2. Surgical Site Infection (SSI) – 2,923
of Health Care is Ours to Imagine,” will be held in
3. Acute Myocardial Infarction (AMI) – 2,893
Nashville December 8-11, 2008
• For the latest on patient safety, visit
UPDATE
http://www.ihi.org/IHI/Topics/PatientSafety/ To learn more, visit www.ihi.org

Joint Commission 2008 National Patient Safety Goals


• Improve accuracy of patient identification • Reduce risk of surgical fires
UPDATE • Improve effectiveness of communication • Encourage patientʼs active involvement in their care
among caregivers • Prevent healthcare-associated pressure ulcers
• Improve medication safety (decubitus ulcers)
• Reduce risk of healthcare-associated infections • Identify safety risks inherent in patient population
(Expanded in 2008 to include either WHO (suicide, home fires)
or CDC Hand Hygiene Guidelines) • Rapid response to changes in patient condition
• Reduce risk of patient harm from falls (new for 2008)
• Reduce risk of influenza and pneumoccocal • Implementation of Universal Protocol for preventing
disease through immunization wrong-site, wrong-person, wrong-procedure surgery

To learn more about the proposed 2009 National Patient Safety Goals, go to www.jointcommission.org and see the News Flash on Page
8 of this issue.

Surgical Care Improvement Project (SCIP): Target Areas


1. Surgical-site infections
By the numbers:
• Antibiotics, blood sugar control, hair removal, normothermia
• 3,740 hospitals are submitting
2. Perioperative cardiac events data on SCIP measures, representing
• Use of perioperative beta-blockers 75 percent of all U.S. hospitals
3. Venous thromboembolism • Currently, SCIP has more than 36
• Use of appropriate prophylaxis association and business partners

CMSʼs 9th Scope of Work is available at cms.hhs.gov/QualityIMprovement9thsow.asp#TopOfPage.


SCIP measures are included in the 9th Scope of work. The 9th Scope of Work began August 1,
2008 and runs for three years. To learn more, see the article on Page 13 of this issue.
UPDATE

To learn more, visit www.medqic.org/scip.

Aligning practice with policy to improve patient care 7


News Flash
CMS Proposes Additions to List of Hospital-
Acquired Conditions for Fiscal Year 2009 Joint Commission Announces
2009 National Patient Safety Goals
On April 14, 2008, the Centers for Medicare & Medicaid Services
(CMS) announced a proposed rule that would update payment The Joint Commission has announced the 2009 National
policies and rates under the hospital inpatient prospective payment Patient Safety Goals and related requirements for accredited
system (IPPS) for fiscal year (FY) 2009, beginning for hospitals and critical access hospitals, accredited ambulatory
discharges on or after October 1, 2008. CMS is proposing to care facilities and offices in which surgery is performed.
select nine categories of hospital-acquired conditions (HACs)
for FY 2009 in addition to the eight selected one year ago. In addition to the existing National Patient Safety Goals,
the following modifications and additions have been made:
Candidate HACs for 2009
• Surgical site infections following specific elective procedures: New:
total knee replacement, laparoscopic gastric bypass and • “Eliminate transfusion errors related to patient
gastroenterostomy, ligation and stripping of varicose veins misidentification” was added to the “Improve accuracy
• Staphylococcus aureus septicemia of patient identification” goal
• Clostridium difficile-associated disease (CDAD) • Accurately and completely reconcile medications across
• Ventilator-associated pneumonia (VAP) the continuum of care.
• Deep vein thrombosis (DVT)/pulmonary embolism (PE) • “Implement best practices for preventing surgical site
• Legionnairesʼ disease infections” was added to “Reduce the risk of health care
• Iatrogenic pneumothorax associated infections.”
• Delirium
• Extreme glycemic aberrancies

The announcement of the additional conditions that are


selected will be made at the same time this magazine is going
to print. We encourage you to go to www.cms.gov to find out
which of the 9 candidate HACs were chosen. Look for
additional information on the HACs selected for 2009 in the
next issue of The OR Connection magazine.

The Results Are In!


Hereʼs what you had to say about The OR Connection

The staff of The OR Connection would like to thank the 582 of


you who took the time to complete our online readership survey!
Weʼve learned a lot from what you had to say, and we wanted to
share some of the results with you!

We learned that Patient Safety is the most-read section of the


magazine, followed closely by OR Issues. We were excited to
learn that 93 percent of you find the information in The OR
Connection to be useful.

We also learned a lot about your priorities. Eighty-eight percent of


you told us that patient safety is a priority, followed by turn-
around time (73 percent), surgical site infection prevention (69 per- Thanks again for your feedback – we look forward
cent), education (35 percent) and new innovation (22 percent). to continuing to hear from you in the future!

8 The OR Connection
News Flash

APIC Announces New Name for Infection


Control Professionals
Study: Time is of the Essence with
Postoperative Indwelling Catheter Use
To articulate the expanding roles of its members, the A recent study found that surgical patients whose
Association for Professionals in Infection Control and indwelling catheters were left in place for more than
Epidemiology (APIC) announced that infection control 48 hours are twice as likely to develop a urinary tract
professionals will now be referred to as “infection infection, resulting in increased length of stays, hospital-
preventionists.” This newly created term joins the list of ization costs and rehospitalizations.
professional titles such as hospitalists, intensivists and
interventionists introduced by the healthcare industry over The study, published in the June 2008 issue of Archives of
the past several years. Surgery, is titled “Indwelling Urinary Catheter Use in the Post-
operative Period: Analysis of the National Surgical Infection
Infection preventionists direct interventions that protect Prevention Project Data.” It was authored by Heidi Wald, MD,
patients from healthcare-associated infections (HAIs) in MSPH; Allen Ma, PhD; Dale Bratzler, DO, MPH and Andrew M.
clinical and other settings around the world. They work with Kramer, MD.
clinicians and administrators to improve patient and
systems-level outcomes and reduce HAIs and related Data used in the study was collected from nearly three
adverse events. thousand U.S. acute care hospitals participating in the Surgical
Care Improvement Project. The study revealed that of the
“The term infection preventionist clearly and effectively surgical patients who had received indwelling catheters, half
communicates who our members are and what they do,” had the catheters in place for more than two days. The group
said Kathy Warye, APICʼs CEO. “Infection preventionists whose catheters were left in for more then 48 hours was twice
develop and direct performance improvement initiatives that as likely to develop a urinary tract infection.
save lives and resources for healthcare facilities, so this
was a natural transition – or a right-sizing of the name – to The study clearly demonstrates that urinary catheters in post-
more accurately reflect their role. By creating a new word, operative patients should be removed as soon as possible to
we hope to raise awareness about what infection preven- decrease the likelihood of an adverse outcome.
tionists uniquely contribute to patient safety, improved out-
comes and bottom line savings to healthcare institutions.” To learn more about the study, please visit http://archsurg.ama-
assn.org/cgi/content/short/143/6/551.
To view the complete press release, please visit
http://www.apic.org//AM/Template.cfm?Section=Home1.

Aligning practice with policy to improve patient care 9


Now is the time.
This is the opportunity.

Medline presents a powerful and comprehensive The six conditions targeted by Prevention Above All
solution to six of the most common hospital-acquired and their complementary Medline product and program
conditions (HACs). solutions are:
• Wrong site surgery
Preventing HACs is one of the most important issues in Surgical Time Out Procedure Drape
health care today. Simply put, the CMS reimbursement • Hospital-acquired infections
changes taking effect October 1 mean healthcare pro- Hand Hygiene Compliance Program

fessionals must eliminate HACs and improve patient • Pressure ulcers


Pressure Ulcer Prevention Program
safety — or risk losing Medicare reimbursement dollars.
• Harm avoidance and patient satisfaction
Educational Packaging
The good news is that almost all HACs are preventable,
• Objects retained after surgery
and with Medline’s Prevention Above All, you will have RF Surgical Detection System™
the knowledge and products to prevent six of the most • Catheter-associated urinary tract infections
common HACs. The program’s multi-layered approach Silvertouch™ Catheter
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bottom line. contact your Medline representative, call
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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Special Invitational Forum
Medline presents an executive Prevention Above All forum focusing on
the implications of the new CMS guidelines, targeted interventions and
practical solutions.

Keynote speaker:
John Nance, JD
A founding member of the
National Patient Safety Foun-
dation and one of the foremost
thought leaders on change in
America’s healthcare system
and a regular contributor to
ABC World News and Good
Morning America, John is
also the author of 18 books,
including his latest, Why Hospitals Should Fly: The
Ultimate Flight Plan to Patient Safety and Quality Care.

Featured speakers:
Deborah Adler Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
Senior designer at the design firm Milton Glaser, Inc. Board certified wound specialist with extensive experi-
and the inspiration behind Target’s ClearRx system ence in wound, ostomy & incontinence care.

Dr. Dale Bratzler, DO, MPH Heidi Wald, MD, MSPH


Medical Director of the Hospital Interventions Quality Im- Assistant Professor of Medicine, University of Colorado
provement Organization Support Center and the Hospi-
tal Quality of Care Measures Special Study Kathy Warye
Chief Executive Officer of Association for Professionals in
Larry Creech, RN, MBA, CDT Infection Control and Epidemiology (APIC)
Vice President Perioperative Surgical Services, Clarian
Health Partners
For more conference information,
Dea Kent, RN, MSN, NP-C, CWOCN visit www.medline.com/special/paa.
Practicing nurse for 20 years and the manager and pri-
mary provider at the Wound Healing Center at St. • Learn about Prevention Above All
Joseph Hospital in Kokomo, Indiana • Speaker biographies
• Select conference presentations (available 8/20)
Dr. Andrew Kramer • Request information on specific interventions
Professor of Medicine, Head of Division of Healthcare
Policy and Research, University of Colorado
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Special Feature

SCIP’s Role in the CMS 9th


Scope of Work Proposal
By Dale Bratzler, DO, MPH On August 1, the Centers for Medicare & Medicaid Services
Medical director, Hospital Interventions Quality launched its next three-year cycle of healthcare quality improvement
Improvement Organization Support Center and the initiatives for Medicare providers, known as the 9th Scope of Work
Hospital Quality of Care Measures Special Study
(SoW). Under the direction of CMS, the Quality Improvement
Organization (QIO) Program consists of a national network of 53
QIOs responsible for each U.S. state, territory and the District of
Columbia. QIOs work with consumers and physicians, hospitals
and other caregivers to refine care delivery systems to make sure
patients get the right care at the right time, particularly patients
from underserved populations. The Program also investigates
beneficiary complaints about quality of care.

Aligning practice with policy to improve patient care 13


The Patient Safety theme is designed to address areas of patient Cardiac
harm by using established, evidence-based research that improves • SCIP Card 2: Surgery patients on a beta-blocker prior to arrival
healthcare processes and systems. Key areas of focus in the that received a beta-blocker during the perioperative period
Patient Safety theme include:
• Improve inpatient surgical safety and heart failure rates Venous thromboembolism
(SCIP/HF) • SCIP VTE 1: Surgery patients with recommended venous
• Decrease the rate of pressure ulcers thromboembolism prophylaxis ordered
(PrU-Nursing Homes and Hospitals) • SCIP VTE 2: Surgery patients who received appropriate
• Reduce the use of physical restraints (PR) venous thromboembolism prophylaxis within 24 hours prior
• Improve drug safety to surgery to 24 hours after surgery
• Reduce rates of healthcare associated
methicillin-resistant Staphylococcus aureus (MRSA) Facilities participating in SCIP are collecting data and then
• Providing quality improvement technical assistance depositing the data in the CMS Clinical Data Warehouse
to nursing homes in need (CDW), a national repository from which hospital-specific
performance rates are derived for public reporting on
The focus of the Surgical Care Improvement Project (SCIP) has Hospital Compare. Additional information is available at:
been the recruitment of hospitals for participation in the programʼs www.cms.hhs.gov/QualityImprovementOrgs (click on “Statement
process measurements. The measurements were defined and of Work”) and at www.medqic.org/scip.
recommended through evidenced-based practice to improve
outcomes of surgical patients.

The specific SCIP measures include:


Infection
• SCIP INF 1: Prophylactic antibiotic received within one hour
prior to surgical incision
• SCIP INF 2: Prophylactic antibiotic selection for surgical patients
• SCIP INF 3: Prophylactic antibiotics discontinued within 24 About the Author
hours after surgery end time (48 hours for cardiac patients) Dale Bratzler, DO, MPH, has been involved in healthcare quality
• SCIP INF 4: Cardiac surgery patients with controlled 6 a.m. improvement on the local, state and national level since 1987.
postoperative serum glucose Dr. Bratzler currently serves as the Medical Director for the
• SCIP INF 6: Surgery patients with appropriate hair removal Hospital Interventions Quality Improvement Organization Support
Center and the Hospital Quality of Care Measures Special Study.

14 The OR Connection
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16 The OR Connection
Eighth in a Series
Patient Safety
Back to Basics

Electrocautery Safety and


OR Fire Prevention
By Alecia Cooper, RN, BS, MBA, CNOR

It could happen at any time, to anyone and when you A 68-year-old man was scheduled for ambulatory surgery to
least expect it. If and when it does, your patient, you and your remove a skin lesion on his right cheek. A moderate amount
coworkers could suffer serious injuries, depending upon the of bleeding was encountered during the punch biopsies and
extent and type of error. an electrocautery device was used to cauterize the skin edges
– igniting the nasal cannula and surgical drapes surrounding
The safe and proper use, maintenance and disposal of the face. The surgeon poured sterile water from the operative
electrocautery equipment in the operating room should never tables on the patient and the nasal cannula to extinguish the
be overlooked or taken too lightly. If you do, you could be fire. The nasal cannula and drapes were removed from the
faced with one of the most terrifying experiences of your patient and thrown to the floor. The nasal cannula continued
professional career. Complications and patient injury due to to burn until anesthesia personnel turned the oxygen off. Once
improper use of electrocautery devices include inadvertent the fire was extinguished, new instruments and drapes were
and advertent thermal injury, burn, fire, cardiac arrhythmias obtained. The patient was re-draped and the procedure was
and interference with pacemakers. Although all are serious completed. A thorough examination indicated first- and
complications, a surgical fire can be the most critical.1 second-degree burns involving both cheeks, as well as the
right nasal vestibule.3
Two devastating cases
Following a successful gallbladder surgery at a metropolitan The history of electrocautery
medical center in Boston, a female patient experienced a flash Cauterization began as a means to stop heavy bleeding,
fire ignited on her midsection. The patientʼs abdomen was especially during amputations. The procedure was simple: a
cleansed following her surgical procedure with an alcohol- piece of metal was heated over fire and applied to the wound.
based cleansing solution. The surgeon then decided to This would cause tissues and blood to heat rapidly to extreme
remove a mole from the patientʼs abdominal area using temperatures, causing coagulation of the blood and thus
electrocautery. Blue flames immediately shot up from her controlling the bleeding. Next came medical instruments
midsection – “similar to a flambé,” the surgeon told state called cauters, used to cauterize arteries.
health investigators. The patient suffered painful first- and
second-degree burns.2 Electrocauterization (also called electric surgery or electro-
surgery) is the process of destroying tissue with electricity. It
According to the ECRI Institute, 44 percent of operating room is widely used in many surgical procedures. The procedure is
fires occur during head, face, neck or chest surgery, when most frequently used to stop the bleeding of small vessels or
electrical surgical tools are closest to the oxygen the patient for cutting through soft tissue. The electrocautery generator
is breathing.2 (ESG), more commonly referred to as an electrosurgical unit

Aligning practice with policy to improve patient care 17


(ESU) or simply as a generator, powers an electrosurgical Monopolar
system with electricity at an appropriate voltage, frequency Current is passed from the active electrode, where cauterization
and waveform for cutting or coagulation, as required. occurs, and the patientʼs body serves as a ground. A grounding
pad is placed on the patientʼs body, usually the thigh, and it
Frequency serves as the returning electrode, which carries the current
To prevent electric shock, an alternating frequency that is back to the machine. The placement of the return electrode is
higher than power from standard wall outlets is used. Normal critical in preventing extensive burns.
AC “house-current” runs at 50-60 Hz and is quite lethal, since
at every alternation nerves and muscles get stimulated, causing Bipolar
violent cramps at 50 to 60 times per second. However, nerve The active and receiving electrodes are both placed at the site
and muscle stimulation cease at 100,000 Hz, due to alterations of cauterization. The probe is usually in the shape of forceps,
being too fast for the cells to pick up. Electrosurgery can be with each tine forming one electrode, cauterizing only the tis-
performed safely at “radio” frequencies above 100 kHz.4 sue between the electrodes.

Cutting vs. coagulation Probes


Different cauterizing effects can be achieved by changing the Different shapes of cautery probes are used for different
voltage of the current as well as the pattern of electric pulses. purposes. A common monopolar probe is pen-shaped but
When lower voltage is used with a continuous alternating cur- ending in a small slender scalpel-shaped spatula of about 5 to
rent (AC), heat is produced very fast and tissue is completely 30 mm. This can be used a both a coagulator and an electric
vaporized at the tip of the probe. The effect is “cutting.” When scalpel. The typical bipolar probe resembles a pair of tweezers
a higher voltage current is used in a pulsed manner, heat is that grasp and cauterize a small piece of tissue. There are
produced more slowly, tissue damage is more widespread and variations of these probes that can be used in both open and
blood coagulates. In many electrosurgery instruments, this is minimally invasive surgical procedures.
called “coagulation” mode. This is used for ablation. Usually a
“blend” setting is available as well. The chance of fire
Electrosurgery electrodes and devices are frequently ignition
Monopolar vs. bipolar sources for surgical fires. These types of fires are a potentially
Both monopolar and bipolar electrocautery involve high- devastating yet preventable adverse event. Thankfully, fires
frequency alternating current and a pair of electrodes, one in the operating room are not frequent. According to ECRI,
referred to as “active” and the other “returning.” The difference only 50 to 100 surgical fires are reported each year – but the
lies in the placement of the electrodes. fires can result in serious consequences to patients, damage
to equipment and interruptions to operations.5

18 The OR Connection
According to one ECRI report, an electrosurgical pencil Nitrous oxide use can increase effective oxygen levels above
caused a drape fire because it was not placed in a non- 21 percent. Like oxygen, nitrous oxide also has a vapor
conductive holster.6 In this incident, a pencil fell off the sterile density greater than 1.0. With a vapor density of 1.53, it will
field, was not removed and instead was left dangling. A surgical collect in low-lying areas as well.6
team member leaned against the pencil, causing it to activate,
arc through the drapes to an instrument table and ignite the ECRI data shows that 74 percent of the reported surgical fires
drapes. The flame spread rapidly up the drapes, vertically from occurred when oxygen levels were elevated above 21
the point of ignition, about two feet off the floor, to the patient. percent. It's important to understand that oxygen may collect
By this time, the fire was burning with such intensity that all and its concentration become elevated. This can occur under
other flammable materials on and around the patient ignited surgical drapes, in clothing, on the surface of the skin due to
and quickly burned. This fire was fatal to the patient. Did you the presence of vellus (short, fine, "peach fuzz" body hair) and
know that that materials burn more quickly when vertical? around masks, tubes or nasal cannula when patients are pro-
vided oxygen or nitrous oxide from compressed gas cylinders
There are three conditions that must be in place for a fire to or piped medical gas systems.6
occur: fuel, oxygen and heat. When brought together, these
components complete the fire triangle. Preventing a fire in the To control oxygen concentration levels
OR can be achieved by controlling the elements that make up ECRI recommends6:
the fire triangle. • That the requirement for 100 percent oxygen for
open delivery to the face (for example, when using
Control ignition sources
nasal cannula) be questioned if a lower concentration
The most common ignition sources in the OR are electrosur-
is consistent with the patient needs.
gical and/or electrocautery equipment and lasers. ECRI
reports that approximately 68 percent of surgical fires involve • Stopping supplemental oxygen at least one minute
electrosurgical equipment and 13 percent involve lasers. We before using electrosurgery, electrocautery or laser
have control over ignition sources.6 surgery on the head or neck.
• Titrating the delivery of oxygen to the patient based
ECRI recommends that during electrosurgery6: on the patientʼs blood-oxygen saturation.
• Remove unneeded foot switches to avoid • Tenting drapes to allow gases to drain away from
inadvertent activation. the operating table.
• Place the electrosurgical pencil in its holster when • Using a properly applied incise drape, if possible,
not in active use and place the electrosurgical unit in to help isolate head and neck incisions from
the standby mode. oxygen-rich atmospheres.
• Allow the tip of the pencil to be activated only by the • Considering use of active gas scavenging of space
individual wielding it and when it is under direct beneath the drapes during oxygen delivery. When
observation of the surgeon. scavenging under the drapes, exercise caution so
• Use only active electrode tips that are manufactured that the space beneath the drapes doesnʼt collapse.
with insulating sleeves. • Avoiding the use of nitrous oxide during
• Do not use electrosurgery to enter the trachea. bowel surgery.
• Do not use electrosurgery in close proximity to
combustible materials and oxygen-rich atmospheres. During oropharyngeal surgery, ECRI
• Dispose of electrocautery pencils properly. For also recommends:
example, break off the cauterizing wire and cap • Suction be used as near as possible to any potential
the pencil. breathing gas leaks to scavenge the gases from the
oropharynx of an intubated patient.
Control oxygen levels
We can control oxygen-rich environments in the OR, which in-
clude any atmosphere where there is greater than 21 percent Control combustible materials
oxygen. While oxygen will not burn or explode, it can cause Combustible materials – fuel that will burn – surround the
materials that will not ignite or that burn slowly in ambient air patient in the OR and include the operating table bedding,
to easily ignite and burn rapidly. The vapor density of pure oxygen headrests, clothing, straps, towels, drapes, sponges, dressings,
(1.1) is slightly heavier than air. This means that pure oxygen hair, intestinal gases, tracheal tubes, body tissue, broncho-
may collect in depressions or under drapes or clothing. scopes, breathing systems, petroleum jelly, adhesives, hoses
Continued on Page 21

Aligning practice with policy to improve patient care 19


Here’s a
tip for you.
Medline’s exclusive Blue Silk™ electrodes are
coated with PTFE, the same non-stick compound
used in Teflon®, enabling them to be wiped clean
with a wet piece of gauze or sponge instead of an
abrasive scratch pad.

Blue Silk electrodes also have rounded edges to


prevent RF current from concentrating too much
energy in one area. All tips shorter than 3 inches in
length features ribbed insulation to make swapping
out tips easy–even with a slippery pencil or when
wearing gloves!

Ribbed insulation

Rounded blade

Vega Series electrosurgical pencils are the perfect


match for our Blue Silk electrodes!

ESPB3002

ESRK3002

To learn more about Blue Silk electrodes


and Vega Series electrosurgical pencils,
contact your Medline representative,
call 1-800-MEDLINE or visit
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www.medline.com
©2008 Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
and equipment covering – and this list is not complete. The insulation
Flammable and combustible liquids are also present in the failure provides
OR, including skin prep solutions, tinctures, degreasers, an alternate elec-
suture pack solutions and liquid wound dressings. trical current path
between the
Understanding what can burn and which liquids are flammable active electrode
or combustible is the first step in managing the fuel load for a and the patient
potential fire. Allow flammable liquid preps (e.g., preps that are return electrode,
alcohol-based or contain acetone) to fully dry before draping resulting in the
and avoid pooling the liquids when they are applied. Be aware burn. To minimize
that pooled liquids can be wicked up into sponges, drapes, capacitive cou-
etc. and may take longer to dry. ECRI recommends that facial pling, use an
hair (e.g., eyebrows, beards and mustaches) be coated with electrosurgical
a water-soluble surgical lubricating jelly to inhibit combustion.6 waveform with
the lowest volt-
Know and practice the fire plan age necessary
Service-specific fire plans have been required for many years. to achieve the
A fire plan is strongly recommend for surgical service. It should desired surgical
be reviewed annually and it is recommended that quarterly fire effect. Instruments that use active electrode monitoring tech-
5

drills be conducted. Surgical staff members should participate nology (AEM) are also effective in preventing capacitive
in at least one fire drill (conducted in the OR) every year, and coupling.7 These devices are shielded and monitored so that
it is especially important to: 100 percent of their power is delivered where intended.
• Talk about what each OR team member will do if presented
with a fire involving a patient. Refer to the Forms & Tools section starting on Page 76 to find
• Walk through the plan and look for areas where response an Electrocautery Checklist and an Electrosurgical Cautery
can be improved. Safety policy and procedure. For additional support materials
• Know who will be responsible for moving the patient, where regarding fire prevention in perioperative services, refer to
the patient will be moved and who will be moving AORNʼs guidance statement “Fire Prevention in the Oper-
critical equipment. ating Room.”

Not all burns are external References

Not all fires and burns are external to the patient. Internal fires
1 Gamal M, Lamont C, Greene FL, eds. Review of Surgery Basic Science and
Clinical Topics for ABSITE. New York: Springer; 2006.
have been reported in the literature involving patients under- 2 Kowalczyk L. Fires during surgeries a bigger risk than thought. Available at:
going laparoscopic procedures in oxygen-rich atmospheres http://www.boston.com/news/local/articles/2007/11/07/fires_during_surgeries_a
(oxygen was mistakenly used for insufflation instead of _bigger_risk_than_thought/. Accessed July 15, 2008.
3 Joint Commission International Center for Patient Safety. Preventing Surgical
carbon dioxide). They have also been caused by the use of Fires: Who needs to be Educated? Available at: www.jcipatientsafety.org/15196.
lasers and non-metallic endotracheal tubes that were ignited Accessed July 15, 2008.
while in the patient. The burning endotracheal tube created a 4 Cauterization. Available at: en.wikipedia/wiki/Cauterization. Accessed July 12,

fire similar to that which might have occurred had a blowtorch 2008.
5 DeRosier JM, Surgical Fires and Patient Surgical Burns. NCPS Tips – August/
scorched the lungs. September 2003. Available at: www.va.gov/NCPS/TIPS/Docs/TIPS_Aug_Sept_
03.doc. Accessed July 14, 2008.
Stray electrosurgical burns can cause internal injuries that 6 Focus on surgical fire safety. ECRI Health Devices. 2003;32(1):4-40.

might be difficult to detect because they may not be visible to


7 Avoiding Electrosurgical Injury During Laparoscopy: An Emerging Patient Safety
Issue. [Videotape] Washington: Communicore; 1997.
the surgeon. Figures show that 67 percent of stray electro-
surgical burns go unnoticed during surgery and that 25 per-
cent of the patients who suffer internal injuries stemming from
these burns during laparoscopic procedures die.7 Insulation
failure on the electrosurgical device that results in burns and
capacitive coupling is cited as being the primary cause of
burns during laparoscopic procedures. With use, the tip of the
ESU can become extremely hot and, if inadvertently touched
to targeted tissue, can cause burns. Capacitive coupling can
occur if there is microscopic insulation failure in the device.

Aligning practice with policy to improve patient care 21


Back to Basics Crossword Puzzle

Electrocautery Safety and


OR Fire Prevention
1 2

3 4

5 6

8 9

10

11 12

13 14

15

16

17 18

19 20

21 22 23

24

25 26

27 28

29

30

1. Register (free) or log in


www.medlineuniversity.com

2. Click Free Courses tab


3. Locate the puzzle and click Learn More,
then Begin Course
4. Certificates are available online after
puzzle completion

22 The OR Connection
Across Down
1 Electrical fires due to the improper use of electro- 2 Do not use electrosurgery to enter the _____.
cautery equipment are a potentially devastating 3 Do not use electrosurgery in close proximity to
yet _____ adverse event. _____ materials and oxygen-rich atmospheres.
4 Complications and patient injury due to improper 12 Electrocauterization is the process of destroying
use of electrocautery devices include inadvertent tissue with _____.
and advertent thermal injury, burn, _____, cardiac 14 Different _____ effects can be achieved by
arrhythmias and interference with pacemakers. changing the voltage of the current as well as the
5 A common monopolar _____ is pen-shaped. pattern of electric pulses.
6 Use only active electrode tips that are manufactured 16 Allow the tip of the pencil to be _____ only by the
with _____ sleeves. individual wielding it and when it is under direct
7 Electrocautery is most frequently used to stop the observation of the surgeon.
bleeding of small vessels or for_____ through soft 18 Electrosurgery can be performed safely at “radio”
tissue. frequencies _____ 100 kHz.
8 Cauterization began as a means to stop heavy 19 With _____ cauterization, current is passed from
_____, especially during amputations. the active electrode, where cauterization occurs,
9 To prevent electric shock, an alternating frequency and the patientʼs body serves as a ground.
that is _____ than power from standard wall outlets 20 _____ of electrocautery pencils properly. For
is used. example, break off the cauterizing wire and cap
10 The placement of the return _____ is critical in the pencil.
preventing extensive burns. 22 It's important to understand that oxygen may
11 _____ fires have been reported involving patients collect under drapes and in clothing and its
undergoing laparoscopic procedures in oxygen-rich concentration become _____.
atmospheres. 23 _____ reports that approximately 68 percent of
13 Preventing a fire in the OR can be achieved by surgical fires involve electrosurgical equipment.
controlling the elements that make up the 25 A grounding pad is placed on the patientʼs body,
fire _____. usually on the _____, and serves as the returning
15 There are three conditions that must be in place for electrode, carrying the current back to the machine.
a fire to occur: _____, oxygen and heat. 26 A _____ setting is available with most electrocautery
17 In bipolar cauterization, the active and receiving devices which allows for cutting and coagulation.
electrodes are both placed at the site of _____.
21 Remove unneeded foot switches to avoid
_____ activation.
24 The typical bipolar probe resembles a pair
of _____.
27 Place the electrosurgical pencil in its _____ when
not in active use and place the electrosurgical unit
in the standby mode.
28 A fire _____ is strongly recommended for
surgical service.
29 When a higher _____ current is used in a pulsed
manner, tissue damage is more widespread and
blood coagulates.
30 _____ what can burn and which liquids are
flammable or combustible is the first step in
managing the fuel load for a potential fire.

To receive one hour of CE credit, enter your answers


online at www.medlineuniversity.com

Aligning practice with policy to improve patient care 23


The average
settlement in
malpractice cases
involving RFOs
is $50,000.2

24 The OR Connection
Patient Safety

Left Behind
Retained foreign bodies harm
both patients and finances
By Megan Giovinco, RN, CNOR, RNFA

A 42-year-old woman presented with a five-month history adhesions and death.2 If this was not enough to make surgical
of abdominal pain, nausea and vomiting. Physical exami- facilities reexamine their count policies, the fact that they will
nation revealed a palpable epigastric mass. Five months not receive their full Medicaid and Medicare reimbursements
prior, the patient had undergone an abdominal hysterectomy if they fail to take steps to prevent eight avoidable hospital-
for uterine leiomyomata. The rest of her examination and acquired conditions – including RFOs – will. In short, if a
history were unremarkable. An abdominal computed tomog- patient must return to surgery to remove a foreign object left
raphy (CT) scan was performed. Review of this and the Scout behind during a previous procedure, the hospital will have to
image from the CT revealed a “density consistent with a foot the bill.5
laparotomy sponge in the left lower quadrant of the
abdomen.” The patient returned to surgery for an exploratory Traditionally, the manual counting of sponges, sharps and
laparotomy and a sponge from her first surgery was found instruments has been a utilized standard of practice in the sur-
and removed.1 gical setting. Although helpful, there is no published data dis-
cussing the effectiveness of this practice.4 In fact, according
How serious is the problem? to a study done by the New England Journal of Medicine, in
Gossypiboma, or retained foreign objects, are a dangerous almost 90 percent of cases involving a retained foreign ob-
and costly issue.2 Current studies have found that retention of ject, a count was performed per policy and all objects were
sponges, sharps or instruments can occur as frequently as reportedly accounted for.6 Certain assistive devices such as
one in every 100 cases or 1 in every 5000 cases. According hanging bags to place sponges in, needle boxes on the sur-
to the American College of Surgeons, any facility that gical field and wall-mounted boards for count documentation
performs 8,000 to 18000 major cases annually will have one have helped, but items continue to be left behind.4
incidence of a retained item yearly.3 These statistics are
based on claims data, but it is highly probable that even more How does this happen?
cases are settled outside the legal system every year. In So why do items get left behind? The surgical team is made
addition, it is likely that many more circumstances where up of dedicated and conscientious healthcare providers –
“near misses” – incorrect counts of sponges and instruments including anesthesiologists, surgeons, nurses and surgical
that were identified and resolved intraoperatively via manual technicians – who are committed to a common goal of safe,
searches and X-rays – have happened.4 The average settle- efficient and effective functionality. These professionals
ment in malpractice cases involving RFOs is $50,000. These constantly execute challenging tasks under considerable time
items that are inadvertently left behind when the surgical pressures, often in chaotic, constantly changing, stressful
incision is closed can cause pain, sepsis, bowel perforation, situations.4 Although these practitioners have been trained

Aligning practice with policy to improve patient care 25


If a patient must return
to surgery to remove
a foreign object left
behind during a previous
procedure, the hospital
will have to foot the bill.

and have the experience to deal with such an environment, them up to date with AORN Standards and Recommended
human error can occur – especially when so many distractions Practices.9 These routine assessments of policy should also
are present.7 Other risk factors that contribute to a greater include investigating any new tools or procedures available
chance of something being missed include emergency surgery, that will increase patient safety and reduce retention
unplanned changes in the procedure, patients with a high of counted items.6 Many institutions encourage obtaining a
body mass index, multiple changes in the surgical team and routine X-ray of any case considered high risk for a RFO,
multiple operative sites.2 such as traumas or morbidly obese patients.3 However, it has
been noted in a recent study that three out of 29 X-rays
Well, what more can be done? As with many things, commu- obtained for an incorrect count falsely reported that no
nication is key. Good communication between the surgical foreign objects were seen on the films.9
team is necessary for the prevention of retained foreign
objects.8 Intraoperatively, distractions, interruptions, noise Technological advances
and traffic should be as limited as possible. When staff New technologies, such as radio frequency identification,
changes occur, complete and accurate transmission of have recently been gaining acceptance in many of the
relevant information must be shared. This information nationʼs ORs. Radio frequency ID-tagged sponges are elec-
should also be documented according to facility policy. To- tronically tagged with a small microchip about 4 x 12 mm in
ward the end of the procedure, the final count of surgical size. This chip is small and sturdy enough that the sponges
sponges, sharps and instruments should be performed and that house it can be used the same way non-RFID sponges
include a visual and audible confirmation by at least two are. Detection is still possible even if the gauze is balled or
team members. This information should then be relayed to folded up. One can even clamp directly over this chip without
the surgeon prior to closure of the surgical site.4 impairing its functionality.10 By passing a hand-held, battery-
powered wand over the patient, one can detect whether or
not a sponge was left behind.9 These RFID chips are available
in sponges, gauze and towels in a variety of sizes. The wand
Although following these guidelines
can also be used off the surgical field by the circulator to scan
will augment accuracy and reduce
errors, the fast pace and ever- for sponges that may have been inadvertently thrown into
changing conditions of the OR the trash.10

This system is not meant to replace the traditional counting


environment do not always allow
system, but to augment it. Since the majority of retained
for them to take place as well as
they would in an ideal setting. sponges happen when the counts are thought to be correct,
a clear scan and a reconciled surgical count give the scrub
It is for this reason that surgical facilities must provide the nurse and circulator the assurance and peace of mind that
resources necessary to establish the safest OR environment their findings are also correct.10 Clinical evaluations performed
possible. 4 Counting policies should be re-evaluated, by surgeons and perioperative personnel have rated the
revised and updated as needed in order to adapt them to the RFID systems very highly for ease of use and the possibility
specific clinical settings of each particular facility and to keep of decreasing the risk of incorrect counts.9

Continued on Page 28

26 The OR Connection
Searching for that
one last sponge?

The RF Surgical® Detection System™ Are You Covered?


Perioperative nurses spend 15 to 30 stressful minutes As of October 1, 2008 Medicare will stop paying for
manually counting surgical sponges and instruments before, objects retained during surgery. Several major insurers
during and after each operation. Even with such protocols, are following suit.
studies suggest that given the 28.4 million inpatient opera- By helping prevent the occurrence and risk of retained
tions performed nationwide, more than 1,500 cases of a surgical objects, the RF Surgical Detection System sets a
retained foreign body occur annually in the United States.1 new standard of patient care and safety in the operating
According to Harvard University researchers, 88 percent of room and helps you avoid the cost of diagnosis, treat-
retained sponge cases falsely recorded a “correct” manual ment, re-operation, legal settlement and the time tracking
count of sponges at the end of the procedure, leading OR disposables.
staffs to unknowingly leave behind sponges in patients.
Developed and Manufactured
Prevent Retained Surgical Objects by RF Surgical Systems, Inc.
RF Detect® is the first easy-to-use scanning system to The RF Surgical Detection System
accurately detect and prevent retained sponges, gauze is exclusively distributed by
and towels in patients. Medline® Industries, Inc.
No larger than a grain of rice, RF Detect brings major
improvements in patient safety to the OR. For more information, contact
your sales representative or call
Reference
1. Popovic JR, Hall MJ. 1999 National Hospital Discharge Survey. Advance data from vital and health
1-800-MEDLINE.
statistics. No. 319. Hyattsville, Md.: National Center for Health Statistics, 2001. (DHHS publication no.
(PHS) 2001-1250 1-0287.).

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

www.medline.com
RF Detect® is a registered trademark of RF Surgical Systems, Inc.
RF Surgical® is a registered trademark of RF Surgical Systems, Inc.
Performing surgical counts accurately and efficiently is one
of the first things taught to perioperative professionals.9
Everyone involved in the surgical procedure shares an ethical,
moral and legal responsibility to provide the patient with the
safest possible care. This includes assuring that no foreign
objects are retained where they can cause pain, harm,
further surgery or even death. To do this calls for the following
guidelines set up by the American College of Surgeons to be
followed:2
• Effective communication among perioperative staff
• Consistent application and adherence to individual facility
standards for counting procedures
• Performance of a methodical wound exploration prior to
closure of the surgical site
• Use of X-ray detectable items in the surgical site
• Maintenance of the most optimal OR environment possible
to allow for focused performance of tasks
• Use of X-ray and RF technology as indicated to ensure
there are no items remaining in the surgical field

There are many variables during the


count process that can potentially
lead to errors related to retained
foreign objects.
These include trauma situations, sudden changes in patient
References
status, obesity, noise and traffic in the room and staff changes 1 Brown M, Schabel S. Retained laparotomy sponge. Applied Radiology.
intraoperatively. However, it is still the number one priority of 2004;33(1).
all members of the surgical team to ensure the patientʼs 2 Cedars- Sinai: OR Elimination of Retained Foreign Objects Taskforce. Nothing left
behind. Available at: www.csmc.edu/11749.html. Accessed July 18, 2008.
safety. OR personnel must utilize their knowledge and experience 3 Jackson S, Brady S. Counting difficulties: retained instruments, sponges and
and remain diligent and focused during the counting phases needles. AORN Journal. 2008;87(2):315-321.
of the surgical procedure so that no patient has to suffer from 4 Gibbs VC, McGrath MH, Russell, TR. The prevention of retained foreign bodies

a retained item.3 after surgery. Bulletin of the American College of Surgeons. 2005;90(10).
5 Brandon G. Rule denying payments for “never events” will force a close look at
current practice. AORN Management Connections. October 2007:3(10).
6 The Joint Commission International Center for Patient Safety. Reducing the risk of
unintentionally retained foreign bodies. Available at:
http://www.jcipatientsafety.org/15199/. Accessed July 18, 2008.
7 RF Surgical Systems Inc. Retained surgical objects: costly to avoid and over-
come… until now. Available at: www.rfsurg.com/retainedobjects.htm. Accessed July
18, 2008.
8 American College of Surgeons. [ST-51] Statement on the Prevention of Retained
Foreign Bodies after Surgery. Available at: http://www.facs.org/fellows_info/state-
ments/st-51.html. Accessed July 18, 2008.
9 Murdock DB. Trauma: when thereʼs no time to count. AORN Journal. February
About the author 2008:87(2):322-28.
Megan Giovinco, RN, CNOR, RNFA, currently a clinical nurse 10 RF Surgical Systems Inc. Features. Available at: http://www.rfsurg.com/fea-
tures.htm. Accessed July 18, 2008.
consultant, has been an RN for more than 10 years. Previously,
she worked as a nurse at a number of acute care facilities and
trauma centers.

28 The OR Connection
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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Patient Safety

World Health Organization Issues


Safety Checklist for Surgical Teams
By Laurie Barclay, MD and
Brande Nicole Martin

To improve surgical safety worldwide, likelihood that patients will receive a higher
the World Health Organization (WHO) has standard of surgical care, with adherence
released a new safety checklist for surgical to these standards improving from 36% to
teams to use in operating rooms, accord- 68%, and to nearly 100% in some hospitals.
ing to a report regarding the Safe Surgery Better adherence has been linked to
Saves Lives initiative, published online significant reductions in surgical morbidity
June 25 in The Lancet and also available and mortality, although final results are not
on the WHO Web site. These WHO guide- yet available.
lines and checklist are the first edition, and
they will be finalized for dissemination by late The checklist covers 3 phases of a surgical
2008, after completion of evaluation in 8 pilot procedure: before anesthesia is induced,
sites globally. before skin incision, and before the patient
leaves the operating room. For each phase,
"Preventable surgical injuries and deaths are now a growing a checklist coordinator confirms that the team has com-
concern," Margaret Chan, MD, director-general of WHO, says pleted the designated tasks before the next phase of the
in a news release. "Using the Checklist is the best way to operation occurs.
reduce surgical errors and improve patient safety."
Before induction of anesthesia, key components of the
High mortality and morbidity of major surgical procedures mandate checklist, using the mnemonic "Sign In," are as follows:
global public health and surveillance measures to improve
surgical safety, especially in low-income areas with limited • Check that the patient has confirmed their identity, the
surgical access. Estimates suggest that about half of surgical surgical site, and the procedure to be done and that the
complications may be preventable. patient has given informed consent.
• The surgical site should be marked, if applicable.
The Safe Surgery Saves Lives initiative, a collaboration of more • The anesthesia safety check should be completed.
than 200 national and international medical societies and • The pulse oximeter should be placed on the patient
ministries of health led by the Harvard School of Public Health,
and functioning.
aims to reduce avoidable surgical mortality and morbidity. The
• Check to see if the patient has (1) A known allergy. If so, these
newly developed WHO Surgical Safety Checklist provides a set
should be documented. (2) An anatomically difficult airway to
of surgical safety standards applicable to all countries and
intubate or aspiration risk. If so, additional equipment and
health settings.
assistance should be available. (3) Risk of more than 500-mL
blood loss in adults or 7 mL/kg in children. If so, provision
At 8 pilot sites worldwide, preliminary findings from 1000
should be made for adequate intravenous access and fluids.
patients suggest that using the checklist has nearly doubled the

30 The OR Connection
Before skin incision, the checklist uses the mnemonic Before the patient leaves the operating room, the
"Time Out" for the following components: checklist uses the mnemonic "Sign Out" for the
following components:
• Confirm that all team members have introduced themselves
both by name and by their role on the surgical team. • The nurse verbally confirms with the team the name of the
procedure to be recorded and verifies instrument, sponge,
• The surgeon, anesthesia professional, and nurse should and needle counts, if applicable; labeling for the surgical
verbally confirm the patient's identity, surgical site, and specimen, including patient name; and whether there are
procedure to be performed. any equipment problems to be addressed.

• Anticipated critical events to be reviewed by the surgeon • The surgeon, anesthesia professional, and nurse review
the key concerns regarding recovery and management of
are any critical or unexpected steps, estimated operative
the specific patient.
duration, and anticipated blood loss.

The WHO notes that the checklist is not intended to be


• Anticipated critical events to be reviewed by the anesthesia
comprehensive but encourages specific modifications and
team are whether there are any patient-specific concerns.
additions appropriate for each local practice.

• Anticipated critical events to be reviewed by the nursing team "Surgical care has been an essential component of health
are confirmation of sterility of the tools, supplies, and field systems worldwide for more than a century," says checklist
(including indicator results); documentation and discussion coauthor Atul Gawande, MD, MPH, a surgeon and professor
of any equipment issues or concerns; whether antibiotic at Harvard Medical School in Boston, Massachusetts.
prophylaxis has been given within the last 60 minutes, if "Although there have been major improvements over the last
applicable; and whether essential imaging is displayed, few decades, the quality and safety of surgical care has been
if applicable. dismayingly variable in every part of the world. The Safe
Surgery Saves Lives initiative aims to change this by raising
the standards that patients anywhere can expect."
Lancet. Published online June 25, 2008. Reprinted with permission.

World Health Organization. Implementation Manual WHO Surgical Safety


Checklist (First Edition). Available at: http://www.who.int/patientsafety. A copy of The WHO Surgical Safety Checklist can be found on Page 86

Aligning practice with policy to improve patient care 31


Moments of Truth
How to enact a
culture change
at your facility
We hear a lot about culture change in health care these
days. Terms like “culture of safety,” a “just culture,” a “safety
culture” or the “culture of a high-reliability organization” pepper
the conversations of folks talking about patient safety and how
to improve it. Just what is culture and how do you go about
creating the culture you want?

By Stephen W. Harden

32 The OR Connection
Special Feature

Defining culture
There are numerous definitions of culture. Everyone seems
to have their own take on it. After working with over 80 healthcare
organizations in the past eight years to help them create and
sustain a culture of safety based on the best practices of
high-reliability organizations, I have come to believe the
definition of culture is this: “The cumulative effect on the
organization of the actions of the people within the organization
at daily moments of truth.”

The heart of this definition is what people do at the daily


moments of truth. Intrinsically, you know what a moment of
truth is – the tens, if not hundreds, of little decision points
every healthcare professional encounters in the course of
their daily activities. A decision point is where a choice must
be made. You can do “A” or “B.” You can do something or
nothing. You can say something or say nothing. You can do
it the right way or use a work-around. You can do it mindfully
or thoughtlessly. Many of these decisions are decided almost
on the subconscious level, sometimes out of habit – without
even being aware of deciding.

The formula for culture change


So if we want to change culture, then we must influence what
happens at the thousands of daily moments of truth in an
organization. There is a simple formula for this. Remember
that “simple” does not always mean “easy.” This formula is
simple to understand and difficult to follow. The formula for
changing culture is this:

Thoughts + Actions + Habits + Character = Culture

Changing culture begins with changing how folks think at the


moment of truth. If you can change how they think, affect why
they do what they do, then you can change how they act at
the moment of truth. If we can change their thinking long
enough to affect how they act on a repetitive basis, then we
can help them develop habits. Habits are those actions we
take almost without thinking – itʼs just the way we “do busi-
ness” on a personal level. Changing habits changes our char-
acter. Character is what we do, again almost at the
subconscious level, especially when we think no one is
watching or no one will know.

Aligning practice with policy to improve patient care 33


Leading a Change Initiative

"Your success in life isn't based on your ability to simply


change. It is based on your ability to change faster than
your competition, customers and business."
- Mark Sanborn

Questions to ask when considering change:


• What do we want to change?
• Why do we want to change?
• How are we going to change?
• Will change make things better?

Often, change does not bring about the desired out-


come, or is only temporary. Permanently changing the
culture of an organization requires taking the right
steps in the right order.

Is your team resistant to change? Listed below are


three key components required to leading an effective
change initiative:
Ultimately, culture is determined by the collective character
of all of the people in the organization. Their character is 1.Planning - Leading a change initiative requires a
determined by their habits. Their habits are determined by compelling vision, a plan to achieve that vision,
how they repeatedly act at moments of truth. Their actions at and time to implement the plan. Anticipate potential
that moment are determined by how their thought processes obstacles and plan for overcoming or avoiding them.
have been influenced. So if you want to change culture, you Achieve sustainability by anchoring your changes
must change character, and if you want to change character into your organization's culture. Don't forget to
you must change habits, and if you want to change habits schedule in short-term win opportunities within
you must change repetitive actions, and if you want to your long-term planning. This will encourage
change actions you must change how people think. forward movement.

2.Training - Provide training and support during


In my experience, the most effective way to change how
implementation. Plan for training of new-hires and
people think is through leadership actions. These actions
staff turnover as this will help to ensure sustainability.
include steps such as:
Make certain the proper equipment is available to
• Over-communicating what must be done, how it must be
support your change initiative. You can't successfully
done and why it must be done; run a new software program system-wide when most
• Aligning all of the documents that describe how business of your team is still using dinosaurs for computers.
is done in the organization with the philosophy of how Avoid regression by celebrating the "battle won" too
it should be done; soon, but celebrate your teams' successes along the
• Public and repetitive acknowledgment and rewarding way as this will build confidence.
of the desired actions at the moments of truth;
• Consistent coaching for those needing improvement and 3.Human power - Are you adequately staffed to lead
willing to improve and this change initiative? Do you have champions in
• Imposing negative consequences for those unwilling to place? Are your champions equipped with a common
change how they think and act. vision? Avoid overburdening an already overburdened
team. Consider restructuring and adding new team
To change how people act at the moment of truth, training is members to better ensure change and desired
most effective. “Telling” is not training. Great training that outcome.
changes actions is experiential, inter-disciplinary, case study-
based, allows for practice and offers real-time feedback and Reprinted with permission from LifeWings. To learn
reinforcement on performance. Effective training gives both more, visit www.saferpatients.com.
the individual and the team an opportunity to practice the

Continued on Page 36

34 The OR Connection
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References
1 Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol. 2000;21:381-386.

www.medline.com
2 Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Healthcare Purchasing News. Available at:
http://www.hpnonline.com/inside/2003-11/1103hygiene.htm. Accessed November 20, 2007.
actions needed in a learning environment so they will skillfully
be used at the moment of truth.

To ensure those actions are repeatedly used when needed


and therefore made into a habit, hardwired tools are most
effective. Tools such as checklists, protocols, communication
scripts, standardized communications and briefing guides
help people use the right action at the right moment. The tools
serve as a forcing function: if the tool is used correctly as part Continue your CE
of the consistent daily work flow, the individual has no choice
but to take the right action repeatedly and thus develops an
coursework at
effective habit. Medline
Little by little, moment by moment, person by person, habits University
are ingrained and character changes. When character
changes, the culture will change. Simple, but not easy. The Courses you can attend at any
beauty of the LifeWings methodology is that each of the time, from anywhere you have
components necessary to affect thinking, actions and habits
Internet access.
are built into our process and our expert facilitators and
coaches demonstrate and teach the skills to follow the
Medline University offers more
culture changing formula.
than 50 self-study nursing
Perhaps your initiative will become guided by this quote from CE-credit courses.
Thomas Carlyle:
An affordable online resource.
Visit www.medlineuniversity.com
“Culture is the process by which a person
becomes all that they were created capable
of being.”
As you and I together continue to create and sustain cultures
where healthcare professionals are allowed to be capable of
all they were created to be, we will truly change the patient
safety landscape in this country.

About the author


Stephen W. Harden is President of LifeWings Partners LLC and
co-founder of Crew Training International, Inc. (CTI), the parent
company of LifeWings. Prior to his position at LifeWings, he was
the principal courseware designer of CTIʼs Crew Resource
Management (CRM) training for the U.S. Air Combat Command,
Air National Guard, Air Force Reserve Command, Italian Air Force,
Swiss Air Force, Belgian Air Force, domestic and commercial
airlines, construction crews and hospital surgical teams.

36 The OR Connection
Surgical Site
Infections
Are you playing your part
in prevention?

By Dayna Lowe, CST Instructor

Postoperative surgical site infections, also known as SSIs, are


quickly becoming the most common type of nosocomial
infection in patients undergoing surgery. They can lead to
increased morbidity, mortality, length of hospital stay and healthcare
costs.1 These infections number approximately 500,000 per year,
among an estimated 27 million surgical procedures.2 Postoperative
surgical site infections account for about one quarter of the estimated
2 million nosocomial infections in the United States annually.3

Everyone has a part to play in prevention


Surgical technologists, nurses,
Postoperative surgical site infections are not to be taken lightly. anesthesia care providers and surgeons
The occurrence and nature of SSIs vary from facility to facility, surgeon
to surgeon as well as from patient to patient. For the operating
alike can greatly impact the outcome
room team, the warlike struggle against SSIs is complex. Each of each surgical procedure by following
team member caring for the surgical patient plays an important role
in the prevention of postoperative surgical site infections. Surgical
the structured protocol proven to prevent
technologists, nurses, anesthesia care providers and surgeons
postoperative surgical site infections.
alike can greatly impact the outcome of each surgical procedure by
following the structured protocol proven to prevent postoperative sur-
gical site infections.
with the instruments intended for use after the anastomos
The surgical technologist is is completed.
Surgical technologists have the primary responsibility for main-
taining the sterile field and remaining vigilant in verifying that all This technique requires knowledge of anatomy as well as exceptional
members of the team adhere to an aseptic technique.4 Without this organizational skills. A surgical technologist with a healthy surgical
constant vigilance by the surgical technologist, the occurrence of conscience and a general understanding of the surgeries in which
inadvertent contaminations could go unnoticed and ultimately lead they partake is a valuable team player in the fight against SSIs.
to a postoperative surgical site infection. The dedication of the surgical
technologist to uphold this responsibility is known as a “surgical The circulating nurse
conscience.” A surgical conscience is defined as “the ethical and Prior to undergoing a surgical procedure, the patient is prepared for
professional motivation that regulates oneʼs aseptic technique.”5 surgery by the circulating nurse. This preoperative routine carried
out by the circulating nurse often involves hair removal and
Along with a surgical technologistʼs close watch over the operative decontamination of the surgical site. It is believed that preoperative
field, the tech must be aware of which surgical procedures require surgical site hair removal reduces infection rates; in contrast, some
a clean and dirty instrument setup. For example, in a procedure methods of surgical site hair removal have been found to increase
involving the gastrointestinal tract, the surgical technologist is the likelihood of SSIs.7 For this reason, healthcare facilities have
presented with the challenge of maintaining a clear definition begun using electrical clippers verses the old-fashioned method of
between instruments involved with the contaminated portion of the dry shaving with a razor.
procedure and the portion of the procedure that must remain sterile.
In order to do so, the surgical technologist must provide the members In addition to hair removal, the circulating nurse is most often
at the surgical site with a sterile basin dedicated to the reception of responsible for the decontamination of the patientʼs skin with an
the contaminated instruments just before the surgeon opens the antiseptic solution. The purpose of the skin preparation is to
bowel.6 Throughout the duration of this portion of the procedure, it reduce and ultimately remove pathogenic transient microorganisms
is imperative that the surgical technologist does not come in contact from the epidermal and dermal surfaces.5 The Association of peri-

Aligning practice with policy to improve patient care 37


THESE INFECTIONS
Operative Registered Nurses states immediately before extubation,
that when selecting antiseptic with the concentration returned to
agents, one should take into 80 percent by the anesthesiologist.12
consideration the types of tissue
The surgeon
number approximately
involved. AORN emphasizes
that one should choose an agent 500,000 per year, among The surgeon is the individual most
with a broad range of germicidal responsible for prescribing the
action and also apply it in accor- preoperative antibiotics. Preoper-
an estimated 27 million
dance with the manufacturerʼs surgical procedures.2 ative administration of antibiotics
written instructions. is a course in prevention. The
rationale suggests that if there is
The circulating nurse also plays a crucial role in maintaining the an infusion of antibiotics in the tissue prior to incision, there is
patientʼs body temperature, which can greatly influence the risk less of an opportunity for opportunistic bacteria to find a home
of SSIs. Although it seems more of a courtesy than structured in the patientʼs surgical incision. An intricate combination of
protocol, the provision of warm blankets can ensure the patientʼs timing, selection, duration and discontinued use is vital to the
core temperature is at the homeostatic state at the time success of an antibiotic.
of induction.
In a successful surgery, each individual team member plays an
The anesthesia care provider important role. Although certain tasks and preoperative routines
Attention to the patientʼs body temperature is a standard of care are delegated to the staff, a system of accountability is useful to
in anesthesia management. Operating rooms are kept at a maintain an ideal approach to preventing SSIs. A medical
cool temperature because it has long been believed that caregiverʼs continued education in the advances in aseptic tech-
doing so minimizes the risk of infection. Recent studies suggest niques, and overall prevention of surgical site infections, can
that this is not the case at all. Lowering the core body tempera- help ensure a smooth, infection-free recovery for the patient.
ture causes dermal vasoconstriction and reduced blood flow to
surgical sites, thus taking away life-sustaining oxygen.8 Both About the author
regional and general anesthesia can cause the bodyʼs core Dayna Lowe has been a surgical tech-
temperature to drop. In an attempt to prevent intraoperative nologist for six years. She currently works
hypothermia, the anesthesia care provider often employs the at a smaller hospital in Florida and as an
use of a forced-air warming blanket. Instructor of Surgical Technology at Central
Florida Institute.
Another action the anesthesia care provider takes that aids in
the patientʼs ability to avoid an SSI is the administration of the
prophylactic antibiotic(s) in a timely manner. In fact, two national
organizations, the Centers for Disease Control and Prevention References
1 Perl T. Identification of Risk Factors Associated with Surgical Site Infection following Spinal Sur-
(CDC) and the American Society for Health System Pharmacists gery. Study currently underway at Johns Hopkins University.
(ASHP), have recently collaborated to provide medical caregivers 2 Centers for Disease Control and Prevention. National Center for Health Statistics. Detailed

with guidelines regarding the administration of prophylactic


Diagnoses and Procedures, National Hospital Discharge Survey, 1994. Hyattsville, Md.: Department
of Health and Human Services; 1997.
antibiotics for a variety of procedures.9,10 Administration of 3 Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection

antibiotics, usually intravenously, should be timed so that a bac- rate: a new need for vital statistics. Am J Epidemiol. 1985;121:159-67.
4 Commission on Accreditation of Allied Health Education Programs. Surgical Technologist. Avail-
tericidal concentration is present in blood and tissues by the time able at: http://www.caahep.org/Content.aspx?ID=53. Accessed July 1, 2008.
the surgical incision is made and maintained until closure of the 5 Fuller JK. Surgical Technology: Principles and Practice. 4th ed. St. Louis, Mo.: Elsevier Saunders;

surgical site. Because of the overwhelming positive impact of the


2005.
6 Alexander FM. Maintaining a sterile field during gastro-intestinal surgery. The American Journal
studies done on the administration of prophylactic antibiotics, it is of Nursing. 1952;52(6):705-07.

now a standard of care and recommended practice in most 7 Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection.
Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004122.
healthcare facilities. 8 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-
wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.

In addition to the responsibilities discussed above, the anes-


N Engl J Med. 1996;334:1209-15.
9 American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial
thesia care provider is accountable for monitoring the patientʼs prophylaxis in surgery. Am J Health Syst Pharm.1999;56:1839-88.

blood oxygen saturation. Decreased oxygen levels devital-


10 Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory
Committee. Guideline for prevention of surgical site infection. Am J Infect Control. 1999;27:97-132.
ize tissue and increase the risk for bacterial colonization.11 11 Hopf HW, Hunt TK, West JM et al. Wound tissue oxygen tension predicts the risk of wound in-
Providing the patient with an oxygen supplementation involves fection in surgical patients. Arch Surg. 1997;132:997-1004.
12 Greif R, Akca O, Horn EP, Kurz A, Sessler DI. Supplemental perioperative oxygen to reduce the
the delivery of 80 percent oxygen and 20 percent nitrogen incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med. 2000;342:161-67.
through the use of an endotracheal tube, a sealed mask, a
manifold system or a conventional non-rebreather mask for the
first two hours of recovery. Oxygen is increased to 100 percent

38 The OR Connection
Slay bacteria
with silver.

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Arglaes family of products harnesses the power of con- Arglaes® Film is ideal for managing bioburden on post-
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trolled-release silver and Arglaes® Powder is the perfect
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Arglaes : solution for your difficult-to-dress wounds and can be
• Reduces bioburden easily combined with other dressings to create a system
• Provides constant antimicrobial protection for bioburden control.
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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Great Ideas from Your Peers

Surgical Skin Prep Solutions By The OR Connection staff

At St. Vincentʼs Medical Center in Indianapolis, Indiana, solution, particularly as it relates to reducing facility-
Paul Durgan, staff educator for surgery, came up with acquired infections following surgical procedures.
an innovative way to assist surgical personnel in
providing the most effective prep solution in an This led to the idea of creating a custom surgical prep tray
efficient and cost-effective manner. Paulʼs goals were that only contained supplies that could be used in almost
to offer a high-efficacy surgical prep solution while simul- every procedure. Of course, Paul wanted to be sure that
taneously reducing the waste associated with the facilityʼs chlorhexidine was the preferred prep solution, so they
current prep kit. He had observed staff members choose a four-ounce bottle containing 4 percent CHG.
discarding most of the contents in their current prep Additional components in the tray include 100 ml saline
tray and adding their preferred solution. (for diluting or rinsing), three sponge sticks, six winged
sponges, two cotton swab applicators, two blue cloth towels
The CDC strongly recommends using 2 percent chlorhex- and two white cloth towels. They chose cloth towels for
idine (CHG) solution for skin antisepsis. Two percent better absorbency and also because they have much less
chlorhexidine solution has been shown to be six times memory than a paper towel, which can spring back after
more effective than alcohol and povidone-iodine in placement and lead to cross contamination.
cleaning the skin and in inhibiting microbial growth for
days afterward.1 In two studies measuring persistent
Creating a custom surgical prep
efficacy, chlorhexidine demonstrated significant residual
tray enabled St. Vincent’s to realize
antimicrobial effects for five days and was more effective
a 29 percent cost savings over their
than isopropyl alcohol, alcohol or povidone-iodine alone.1
previous trays. They lowered their
per-tray cost by $2.78.

Paul had the opportunity to attend a seminar in which Dr. Because CHG cannot be used to prep eye, ear or genital
Allan Morrison Jr., an epidemiologist and chairperson of procedures, the need for additional prep solutions is appar-
Infection Control at Inova Fairfax Hospital and clinical ent. Paul is actively searching for a CHG prep that can be
assistant professor at Georgetown University Hospital, used on genital areas and will let us know when he finds
discussed the benefits of chlorhexidine as a surgical prep his next solution.

40 The OR Connection
OR Issues

St. Vincentʼs orthopedic department has also recently Improved efficiency, decreased waste, better patient care
initiated a study with their total joint patients, asking them and cost savings are all the results of one innovative
to shower with CHG the night before their surgery. The change. Whereas there is often a perception that
CDC also recommends that surgical facilities require customization leads to increased cost, when you find that
patients to shower or bathe with an antiseptic agent at standardized solutions result in throwing away supplies
least the night before surgery.2 Additional information will that are not wanted or used, one can easily see where
be shared as the results of this study become available. customization can provide a cost effective solution.

Paul Durgan has been the staff educator for surgery at St.
Vincentʼs Medical Center in Indianapolis, Indiana, since 2005.
Paul says that this position has helped him “attain a broader
Components of the Custom Surgical Prep Tray perspective of current needs for patient care as well as physician
and associate satisfaction.” He credits the development of the
• Four-ounce bottle of 4 percent CHG CHG prep kit as an area in which he was able to promote a cost-
• 100 ml saline (for diluting or rinsing) effective solution to one of his facilityʼs needs.
• Three sponge sticks
• Six winged sponges
References
1 Hibbard J et al. A clinical study comparing the skin antisepsis and safety of
• Two cotton swab applicators ChloraPrep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. Journal of
Infusion Nursing. 2002;25(4):244-49.
• Two blue cloth towels 2 Nichols RL. Preventing surgical site infections: A surgeon's perspective.
• Two white cloth towels. Emerging Infectious Diseases. 2001;7(2).

Aligning practice with policy to improve patient care 41


It all adds up. The Pressure Reducing OR Table Pad

Pressure Free is treated with Ultra-Fresh, making it antimicrobial


throughout. It is also antifungal, fluid proof, stain, fungal and fire
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To learn more about our


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pads, contact your Medline
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Pressure Free, Medline’s new OR table pad features 3 layers of www.medline.com.
foam covered in our exclusive Nirvana “Memory” Foam which not
only completely conforms to the patient’s body contours and
Pressure Free
gently cradles delicate bony prominences but keeps its shape
OR table pad
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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Patient Safety

Flipping the Switch on Pressure


How to help reduce your patients’
pressure ulcer risk
By Jayne Barkman, RN, CNOR

After a leisurely lunch in the outdoor café, Sandy and Joe dimmed and then the case was underway. This will be a quick
checked their afternoon assignment. They were to relieve case, Sandy thought to herself as she opened the vial of sterile
the staff in OR 31. Sandy and Joe entered the OR through the talc to the field. She finished her computerized charting and,
sterile core as the surgeon was initiating the time-out. Joe within what seemed like minutes, Joe was ready to do the first
opened his gown and gloves while Sandy received report from closing count. After they completed their counts, Sandy opened
the circulating nurse. The patient was a young anorexic woman the chest drainage tubing to the sterile field and filled the chest
with no known allergies who was undergoing a right thora- drain with water. The second counts were completed soon after
coscopy and chemical pleurodesis for recurrent pneumothorax. and Sandy called for moving and lifting help as Joe placed the
She was positioned in a lateral position right side up on a dressings over the small incision sites.
bean-bag positioner. A towel roll was placed under her axilla.
Her arms were padded with foam and pillows and secured on Joe removed the drapes from the patient as the surgical assis-
arm boards with two pillows placed between her legs. She was tants brought the stretcher into the room and stood at the side
secured to the OR bed by a safety strap across her thighs as of the operating room table in preparation for repositioning of
well as tape across her hips. the patient for extubation.

After he was gowned and gloved, Joe handed Sandy the light Joe asked Sandy to step around to his side of the OR bed. He
and camera cords. The surgeon asked for the room lights to be pointed to an area where a portion of the draw sheet covering

Aligning practice with policy to improve patient care 43


the bean-bag positioner had Sandy agreed and said she would
shifted during the procedure and talk to Sue, the director, to get the
the decompressed bean bag in-service scheduled as soon as
IT IS IMPERATIVE
was pressed directly against the when positioning the patient that possible.
patientʼs skin. The standard of
care at their hospital for lateral all potential pressure points are How to take the pressure
positioning of patients included off your patients
placing foam padding between In the perioperative environment,
adequately padded as well.
the patient and the bean bag as nurses are presented with myriad
well as placing a gel roll under challenges when caring for their
the axilla and foam padding under the patientʼs heels. After the patients. Careful attention is given to keeping the patientʼs
bean bag was compressed to reposition the patient, Sandy and body in proper alignment when positioning in order to prevent
Joe assessed the patientʼs skin. A three-inch-long reddened postsurgical neuropathies. It is imperative when positioning
area was noted along the patientʼs mid-thoracic spine where the patient that all potential pressure points are adequately
the bean bag had come into direct contact with the skin. padded as well. When using linens, such as blankets and towels,
for rolls or positioning devices or placing a patient on a thin OR
When the anesthesiologist was ready, the patient was lifted and mattress, you could inadvertently be placing your patient at risk for
placed in a supine position. Sandy assisted the anesthesiologist pressure ulcer formation. Linens, which are readily available in
with extubating the patient and asked Joe to assess the most operating rooms, are often used for positioning patients
patientʼs ankles and feet for any pressure areas. Joe noted a but do not reduce pressure and may result in unrelieved areas
quarter-sized reddened area on the patientʼs left lateral of pressure or friction injuries.1
mallelous. When the patient was rolled onto her right side to
place the transfer device under her, Sandy noticed a plum-sized Studies have indicated that when the
reddened area below her left axilla, yet another pressure area.
The patient was lifted onto the stretcher and transported to the
patient is unable to move during
CVICU. When relaying report to the CVICU nurse, Sandy surgery, it is important that the
pointed out the reddened areas on the patientʼs back, left axilla weight of the patient be uniformly
and ankle as pressure points that needed close monitoring
postoperatively.
distributed on a firm, stable surface
that conforms to the patient, such as
Back in the OR and helping with room turnover, Sandy and Joe a gel or thick foam mattress pad.2
shook their heads. The hospital policy clearly indicated that
foam or gel pads were to be used to pad areas of potential pres- The amount of pressure and the length of time pressure is
sure on all surgical patients. applied to the skin are both critical factors in pressure ulcer
formation. Studies have indicated that high pressure for a short
As representatives on the patient care council, Joe and Sandy time and low pressure for a longer duration have the same
were aware that an order had been placed for additional gel effect on potential tissue damage and the likelihood of pressure
rolls and pads – as these items had virtually disappeared from ulcer formation.2 When pressure is applied to the skin, blood
the OR – and that new pressure-free operating table mat- flow is decreased, leading to potential skin breakdown and
tresses had been ordered for each of the operating rooms to tissue necrosis.3
replace the old table pads, some of which were cracked and
repaired with tape. Pressure ulcer prevention had also been While extrinsic factors such as shear, force friction and pressure
added to the hospitalʼs required annual competency education predispose a surgical patient to the development of pressure
for 2009. Joe suggested to Sandy that the next OR in-service ulcers, intrinsic factors such as the patientʼs nutritional status,
be dedicated to an interactive positioning in-service where staff age, mobility and mental and continence status also place the
volunteers were placed in various positions and could verbally surgical patient at risk of pressure ulcer formation. Recent
relay to their coworkers the areas that felt uncomfortable so the research, however, has indicated that pressure may be the
staff had an understanding of direct areas of pressure patients single most important factor in the formation of pressure ulcers
experience when positioned during their surgical procedures. intraoperatively.3

44 The OR Connection
Intraoperatively Acquired Pressure Ulcers4,5,6
• Initially appear as a burn like lesion. About the author
Jayne Barkman, RN, BSN, CNOR, has 29 years of perioperative
• Occur most frequently in patients undergoing general,
experience in various roles, including surgical technologist, staff nurse
thoracic, orthopedic, cardiac and vascular procedures. and clinical educator. She currently works as a clinical nurse consultant.
• Have been documented to occur in 12 percent to 66
percent of surgical patients.
• Account for 42 percent of nosocomial-acquired References
pressure ulcers. 1 AORN. Recommended practices for positioning the patient in the
• Add an additional cost of up to $60,000 per patient or perioperative practice setting. In: Standards, Recommended Practices,
and Guidelines. Denver, Colo.: AORN, Inc; 2006:587-590.
750 million to 1.5 billion dollars annually.
2 Hoshowsky VM, Schramm CA. Intraoperative pressure sore prevention:
An analysis of bedding materials. Research in Nursing & Health.
1994;17(5):333-39.
3 Edlich RF, Winters KL, Woodard CR, Buschbacher RM, Long WB,
Typically, perioperative nurses have no contact with the patient
Gebhart GH, Ma EK. Pressure ulcer prevention. J Long Term Eff Med
postoperatively and therefore the ramifications of intraopera-
Implants. 2004;14(4):285-304.
tively caused pressure ulcers are unknown to the perioperative
4 Pressure Ulcers Risk Analysis (Healthcare Risk Control November
staff. The Association of periOperative Registered Nurses
2006). Available at: www.ecri.org/documents/patient_ safety_center/
(AORN) recommends doing a thorough preoperative interview
pressureulcers.pdf. Accessed July 23, 2008.
and assessment to determine the appropriate positioning
5 Ankrom MA, Bennett RG, Springle S et al. Pressure-related deep tissue
devices required for each individual patient. Their guidelines
injury under intact skin and the current pressure ulcer staging systems.
state that the perioperative nurse should be involved in
Advances in Skin & Wound Care. 2005;18(1).
positioning the patient as well as monitoring for proper body
6 Wilhelmi BJ. Pressure Ulcers, Surgical Treatment and Principles. Avail-
alignment and the tissue integrity of the patient after position-
able at: http://www.emedicine.com/plastic/topic462.htm. Accessed July
ing and during the surgical procedure. A skin assessment
23, 2008.
should be repeated when the procedure is finished with docu-
mentation of the assessment. The recommended practices also
state that positioning policy and procedures should be acces-
sible to the staff and be reviewed and revised annually.1

Aligning practice with policy to improve patient care 45


Patient Safety

46 The OR Connection
By Claudia Sanders, RN, CFA

Pressure ulcers can develop within two to six hours of the


onset of pressure. Incidence is over 60 percent for high-risk
patients with femoral and/or hip fractures. Elderly patients with
hip fractures have the greatest incidence of new-onset post-
operative pressure ulcers, which typically occur within the first
two postoperative days. About 70 percent of all pressure
ulcers occur in people older than 70 years. Have you had a
patient in your OR lately who was 70 years old with a hip or
knee fracture?

5
GIMME There are many contributing factors for pressure
ulcers, including:
• Circulation
• Mechanical stress
• Temperature
• Too wet/ too dry (moisture)
• Infection
• Chemical stress
• Medications
• Disease
• Nutrition
• Age
• Body build

A number of these factors are out of our control, but others can
be affected positively with the appropriate tools and practices.
Following is a list of five of these factors and some considerations
Five pressure ulcer you will want to examine the next time you are caring for
patients at risk for pressure ulcers.
factors to keep in mind
1. Age
It should come as no surprise that the older we are, the more
fragile our skin becomes. Skin becomes thinner, drier and has
a tendency to break down easily. The elderly are also at a
higher risk for poor circulation. Clearly, these patients need to
be handled with gentle and caring hands.

Keep in mind how long you may have this patient lying on a
stretcher in a holding area. Ask the patient to move themselves
if possible or encourage and help move the patient if they are
lying in one position for long periods of time. And pad those
areas where pressure ulcers most commonly occur when
patients are lying down: back of the heels, knees, buttocks,
tailbone and hipbone. Same goes for when you have
brought the patient into the operating room and placed
him on the operating room bed. Proper positioning of the
patient and padding of bony prominences is vital in preventing
pressure ulcers while patients are in surgery. Your facility may
want to invest in gel table pads for stretchers and operating
room beds as well as gel positioners.

Aligning practice with policy to improve patient care 47


2. Body build 5. Infection
There are two body types that are especially susceptible to When caring for surgical patients with infection, there are extra
pressure ulcers: obese patients and extremely thin patients. considerations to keep in mind. You know your patientʼs skin is
Obese patients are a higher risk due to poor circulation to fatty already compromised by infection and that their immune
tissues. Poor circulation means less oxygen, reduced nutrition system is also compromised. This compromises healing, which
and more risk for pressure ulcers. When appropriate, be sure can set patients up for pressure ulcers.
to use compression stockings to help with circulation and, of
course, assist in preventing deep vein thrombosis (DVT). Do To help prevent pressure ulcers from forming, position the
whatever you can to improve circulation. This may mean using patient properly (and pad bony prominences), help maintain
minimal sutures in the subcutaneous layer. Handle obese good body temperature (keep the OR at a reasonable
patientsʼ tissues with care and consider preoperative and post- temperature) and help maintain the ideal skin moisture
operative oxygen use. environment (if necessary, use pads to help wick moisture from
the patient). Of course, you also want to prevent cross
Extremely thin patients are also at risk because there is less contamination of infection from an open wound to other parts
fatty tissue to “cushion” them. This means their bony promi- of the body. Consider using skin barrier-type products on the
nences are even more susceptible for skin breakdown surrounding areas before prepping an infected wound.
compared to the average-sized patient. We cannot overstress
the importance of padding these areas and padding them with Keep in mind that this is an area we have all dealt with at one
care so as to reduce friction that can lead to skin breakdown. time or another – but with the occurrence of these pressure
ulcers on the rise and changes to reimbursement policies, it is
3. Chemical stress on wounds time to revisit our practices.
As with all surgical procedures, we must first prep the area
where the incision will be made. This requires chemical products About the author
of one kind or another, depending on the surgeonʼs preference. Claudia Sanders, RN, CFA, is currently a
Such chemicals may include povidone-iodine, hydrogen clinical nurse specialist. She has practiced in
peroxide, alcohol, acetic acid or iodophors. All these chemicals the medical field for more than 30 years as
have an important part in reducing infection, but at the same a surgery technologist and periopera-
time they can contribute to skin breakdown. This is a great time tive nurse.
to “think outside of the box” and consider what compromises
the patient has before choosing your preps. In conditions of
extremely compromised skin, consider rinsing with a prep
solution and monitor how hard you rub or clean the operative site.

4. Too wet/ too dry (moisture)


Most of us know the story of Goldilocksʼ search for porridge
and a bed that were “just right.” Well, the skinʼs moisture needs
to be “just right” as well – not too wet and not too dry. When
caring for surgical patients, we need to help maintain this
environment by being mindful of the solutions we use and how
we use them. Donʼt let prep solutions “pool” on or around the
patient. Prep solution can often run down into the creases of
the femoral, buttocks and lower back areas, not to mention the
axillary and neck areas. Do what you can to prevent this and
clean these areas before sending the patient to the recovery
room so these chemicals will not continue to sit on the skin.
Be gentle with this process, especially with the compro-
mised patient.

48 The OR Connection
Join the program
to reduce pressure ulcers.
Medline’s Pressure Ulcer Prevention Program The Pressure Ulcer Prevention Program from Medline will help
you in your efforts to reduce pressure ulcers in your facility.
Systematic efforts at education, heightened awareness and
specific interventions by interdisciplinary healthcare teams
The program includes:
have demonstrated that a high incidence of pressure ulcers
• Education for professional staff and nurse technicians
can be reduced.1
• Teaching materials for you to help train your staff
• Practical tools to help reduce the incidence of pressure ulcers
The main challenges to having an effective pressure ulcer
• Innovative products supported by evidence-based information
prevention program are lack of resources, lack of staff education,
that results in better patient care
behavioral challenges and lack of patient and family education.2

To join the fight against pressure ulcers and for more


Medline’s comprehensive Pressure Ulcer Prevention Program
information on the Pressure Ulcer Prevention Program,
offers solutions to these challenges to promote the reduction
please contact your Medline sales representative or
of pressure ulcers with clinical and educational resources,
call 1-800-MEDLINE.
assessment tools and a complete compatible product line,
designed to work alone or complement your existing program.

The Pressure Ulcer Prevention


Program. Pressure ulcer
prevention made easy.

References

www.medline.com
1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.
2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
The History of the

SURGICAL
TECHNOLOGIST
50 The OR Connection
OR Issues

By Jennifer Bray, SST and Greg Warino, SST

The workplace is full of a wide variety of job titles and technicians. According to this plan, schools were to be
initials to place behind your name. They often sound established at the Army Medical Center and four other
significant, but did you ever wonder where they came general hospitals for the formal education of surgical tech-
from? What caused a need for the professions (and pro- nologists. Prior to this, technicians were simply trained on
fessionals) of today? At some time, every vocation was the job.2
new, including that of the surgical technologist. So what
spurred the need for them? It was not until 1940 that Dr. Parranʼs plans began to be
executed. In 1941, the first school of surgical technology
The advances in medical technology, from antibiotics to was in session. By July of 1942, 410 students were
blood transfusions, have often come during times of war. enrolled. With the entrance of the United States into World
This same setting fostered the need for surgical technol- War II, there was an even greater need for surgical
ogists. Initially, the role of the nurse basically entailed personnel. More schools were quickly established and the
assisting the surgeon during procedures. However, as number of “scrubs” more than doubled in order to meet
various wars depleted nursing resources, other ways of the demand of the military hospitals both at home and
providing patient care during surgery had to be explored.1 abroad.2

In 1939, Dr. Thomas Parran Jr. (then the U.S. Surgeon The nursing shortage worsened as the war continued and
General) proposed the Protective Mobilization Plan, which more and more wounded soldiers were in need of care.
pushed for the training of enlisted medical and surgical Nurses were in great demand to staff not only local facil-

What Does a Surgical Technologist Do?


What roles do surgical technologists play on any given day?*
• Prepare, care for and dispose of specimens
• Prepare patients for surgery - draping, positioning • Apply dressings
In the OR, they

and establishing the sterile field • Operate lights and suction machines
• Set up surgical instruments and equipment • Assist with diagnostic equipment
• Gloving
• Pass instruments and sterile supplies to the surgeon
• Ensure the integrity of the sterile field throughout the procedure • Manage central supply departments
Outside of the OR, they

• Cut sutures • Represent surgical instrument manufacturers


• Perform surgical counts of sponges, needles, supplies and sterile supply services
and instruments
* Association of Surgical Technologists. The Surgical Technologist. Available at:
http://www.ast.org/ads_exhibits/index.aspx. Accessed June 17, 2008.

Aligning practice with policy to improve patient care 51


ities but the hospitals and medical units of distant erative Registered Nurses (AORN) was formed. This
military bases and battlefields as well. Because of this, group would play a major role in the development of the
more corpsmen were trained to assist surgeons during surgical technologist into a formal part of the surgical
procedures. They were also trained to perform tasks such team.4 In 1968, AORN formed the Association of Operating
as anesthesia administration, instrument preparation, aid Room Technicians (AORT) and formal training for surgical
in clamping and retraction intraoperatively and closure of technologists began at proprietary schools. AORN also
surgical incisions. The title Operating Room Technician, helped establish certification credentialing for surgical
or ORT, was established.1 technologists. The AORT initiated the first certifying exam
and gave those who passed it the title of Certified Operating
Early education Room Technician (CORT).1
In the beginning, medical and surgical technologist
students were taught together for the first month and then In 1972, the American Medical Association formally
separated for their clinical instruction. Surgical technologists approved an educational program for the OR technician.
were assigned to hospital In 1978, the Association of
wards or a surgical service. Operating Room Technicians
According to the Surgeon changed its name to what it is
Generalʼs plan, the surgical now known as – the Associa-
course was to only take two tion of Surgical Technologists.5
months. However, it was
quickly determined that more From the humble beginnings
time was needed to train of nothing but on-the-job train-
these students effectively. ing to a nationally recognized
In 1943, the course was association and credentialing
extended to three months certification, the profession of
with only a month of on-the- Authors Greg Warino, SST and Jennifer Bray, SST are the surgical technologist has
job training.2 currently enrolled in the surgical technologist program certainly come a long way. In
at Central Florida Institute in Clearwater, Fla.
the years since Dr. Parranʼs
In 1942, advanced training was offered to select individuals original plans were developed, hundreds of schools of
who had completed the surgical courses. These technol- surgical technology have been established throughout the
ogists were prepared to replace nurses in the forward United States and thousands of students have graduated.
combat areas or to become instructors of future students. Many of these students have also gone on to earn their
Most of their training was provided by nurses in the hospital certification as a surgical technologist (CST), their First
setting. Unfortunately, despite the specialized training and Assistant qualification (CFA) or become instructors.5 The
service these advanced practice technicians provided, professionals who carry these initials behind their names
they were never recognized by the military. This training have this amazing historic timeline to thank for the
ceased in 1945.3 rewarding career they have chosen.

Moving into the modern day References


1 Fuller JK. Surgical Technology: Principles and Practice. 4th ed. Philadelphia, Pa: W.B.
Since the infantry was depleting the Medical Corps of its Saunders; 2005.

male technologists, the department began accepting 2 Office of Medical History, Office of the Surgeon General. Medical Department, United
States Army Medical Training in World War II. Available at:
women into its programs in 1943. The Surgeon General http://history.amedd.army.mil/booksdocs/wwii/medtrain/frameindex.html. Accessed June 17,

requested the recruitment of even more women in 1944. 2008.


3 Association of Surgical Technologists. Surgical Technology for the Surgical Technologist:
So many women answered the call to duty that schools of A Positive Care Approach. 3rd edition. Clifton Park, NY: Delmar Learning; 2008.

surgical technology had to be expanded yet again.3 4 Association of periOperative Registered Nurses. AORN History. Available at:
http://www.aorn.org/AboutAORN/AORNHistory/. Accessed June 17, 2008.
5 Association of Surgical Technologists. About AST. Available at: http://www.ast.org/abou-

The nursing shortages caused by World War II and the tus/about_ast.aspx. Accessed June 17, 2008.

wars that followed it forced operating room supervisors to


question the need for trained non-nursing personnel to
assist during surgery. In 1949, the Association of periOp-

52 The OR Connection
Medline’s Hand Hygiene
Compliance Program

For all the lives you touch.


Now more than ever, hand hygiene compliance is crucial. The Hand Hygiene Compliance Program includes:
Beginning October 1, 2008, the Centers for Medicare & • An instructor’s manual that takes the guesswork out of
Medicaid Services will no longer be reimbursing at a higher planning lessons
DRG for eight hospital-acquired conditions, including • A customizable plug-and-play CD that contains
catheter-associated urinary tract, surgical site and blood- presentations, posters and more
1
stream infections. We know that hand • Forms and tools to serve as reminders and reinforcements
hygiene is the number one • A cost calculator to help you determine the cost of
line of defense against hos- prevention vs. the cost of an infection
pital-acquired infections.2 • A rewards program to recognize those who complete
the course
There’s no such thing as • Patient and family education materials
“overeducating” when it • CE-credit courses for staff
comes to hand hygiene. • A how-to guide on enhancing your presentation skills
Enhance your current
strategy with Medline’s For an on-site presentation of the Hand Hygiene
Hand Hygiene Compliance Program and our Healthy Hands Product
Bundle, contact your Medline representative or visit
Compliance Program!
www.medline.com/handhygiene.

References
1 Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and
fiscal year 2007 rates. Available at: www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf. Accessed November 20,
2007.

2 Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Healthcare Purchasing News. Available at:
http://www.hpnonline.com/inside/2003-11/1103hygiene.htm. Accessed November 20, 2007.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Special Feature

A Place of Healing?
Violence is increasingly
common in health care
By Laura Kuhn
The OR Connection staff writer
Itʼs ironic when you stop and think about it – hospitals are
places where patients go to get better, yet for some
healthcare employees theyʼre also places fraught with
intimidation, harassment and even violence.

The extent of the problem


According to the Council on Surgical and Perioperative Safety
(CSPS), violence in the healthcare workplace is a growing
concern and nurses are at a particularly high risk.1 Between
1996 and 2000, there were 69 homicides reported in the
health services field.2 Twenty-five of every 10,000 full-time
nurses were injured in workplace assaults in 2000. In contrast,
injuries due to workplace assaults occur in only two of every
10,000 employees in most private-sector industries.2

As disturbing as these numbers are, it is estimated that the


actual number of incidents is much higher.2 Violent incidents
often go unreported, possibly due to the perception that
assaults are “part of the job” in the healthcare industry.2 Other
reasons for underreporting include the lack of a solid institu-
tional reporting policy, the belief that reporting will not benefit
the employee and the fear that the report could be viewed by
employers as employee negligence or poor job performance.2

Many patients who are treated in hospitals


and other care facilities are at an increased
risk of exhibiting violent behavior.

54 The OR Connection
Obviously, healthcare workers can’t control
which patients come through the doors of their
facilities. They can, however, have a strategy
in place for preventing violence and effectively
halting it when it does happen.

Defining violence in the workplace waiting rooms, among others.1 Violence is also more likely to
The CSPS defines workplace violence and its elements in its erupt when facilities are understaffed, especially during meal
Statement on Violence in the Workplace1: times and visiting hours.1

Workplace violence includes, but is not limited to, intimidation, Healthcare workers are also more likely to encounter violence
threats, physical attack, property damage and sexual harassment. when they work alone or directly with volatile people, espe-
cially if those people are under the influence of drugs or
Intimidation includes, but is not limited to, stalking or alcohol, have a history of violent behavior or have been
engaging in actions intended to frighten and coerce. diagnosed with certain psychiatric conditions.1

Threat is the expression of intent to cause physical or What can be done?


mental harm. Obviously, healthcare workers canʼt control which patients
come through the doors of their facilities. They can, however,
Physical attack is unwanted or hostile physical contact such have a strategy in place for preventing violence and effectively
as hitting, fighting, pushing, shoving or throwing objects. halting it when it does happen.

Property damage is intentional damage to property. The U.S. Occupational Safety and Health Administration
(OSHA) lists the following as the five key components in the
Sexual harassment is unwelcome advances, requests for prevention of workplace violence2:
sexual favors, and other verbal or physical conduct of a sexual
nature, when submission to or rejection of this conduct Management commitment and employee involvement
explicitly or implicitly affects a person's employment or Management and frontline employees must work together as
education, unreasonably interferes with a person's work or a team or committee for a violence-prevention program to be
educational performance or creates an intimidating, hostile successful. Management must show concern for employee
or offensive working or learning environment. safety and allocate appropriate resources. Employees must
comply with the workplace violence prevention program and
Triggers for violence in the healthcare workplace report violent incidents promptly and accurately.
Many patients who are treated in hospitals and other care
facilities are at an increased risk of exhibiting violent behavior. Worksite analysis
Medical conditions associated with violent tendencies include A worksite analysis is a commonsense look at the workplace
hypoglycemia, electrolyte imbalance, anemia, hypoxia, alcohol to find existing or potential hazards for workplace violence. A
intoxication, pain, dementia and the use of codeine, PCP, threat assessment team, patient assault team or similar task
LSD and other drugs.3 However, while these factors might force or coordinator can assess the vulnerability of the work-
make a person more likely to behave in a violent manner, the place and determine the appropriate actions to be taken.
individualʼs tendency toward violence must still be triggered in
some way.4 These triggers are referred to as “situational factors.”4 Hazard prevention and control
After hazards are identified through the worksite analysis,
There are a number of situational factors present in hospitals design measures should be taken (whether through engi-
that can contribute to violent behavior. These include poor neering or administrative and work practices) to prevent and
environmental design, inadequate security, access to control these hazards.
firearms, poorly lit areas and overcrowded, uncomfortable

Aligning practice with policy to improve patient care 55


Safety and health training
Training and education for both managers and employees If you’re a victim
can ensure that all staff members are aware of potential The Massachusetts Nurses Association (MNA) has
security hazards and how to protect themselves and their
compiled a list titled “Ten Actions a Nurse Should Take
coworkers. Security personnel will also need their own
If Assaulted At Work.” Those ten actions are5:
specific training.
• Get help and get to a safe area
Recordkeeping and program evaluation • Call 911 for police assistance
Recordkeeping is crucial in tracking the effectiveness of a • Get relieved of your assignment
violence prevention program. Examples of records and
• Get medical attention
documents include the OSHA Log of Work-Related Injury and
• Exercise your civil rights, which might include filing
Illness (OSHA Form 300); medical reports of work injury and
supervisorsʼ reports for each recorded assault; records of charges with police
incidents of abuse, verbal attacks or aggressive behavior that • Report the assault to your supervisor
might be threatening, information on patients with a history • Report the assault to your union representative
of past violence, drug abuse or criminal activity; documenta-
• Get counseling or assistance for Critical Incident
tion of minutes from safety meetings and records of all train-
Stress Debriefing (CISD) to prevent post-trauma
ing program, attendees and qualifications of trainers.
symptoms
Employers who would like to learn more about implementing • Get copies of all reports and keep a diary of events
an appropriate workplace violence prevention program • Return to work only when you feel safe and supported
are encouraged to contact the OSHA Consultation Service
at (800) 321-OSHA. You can also learn more at www.osha.gov.2

References
1 Council on Surgical & Perioperative Safety. Statement on Violence in the Work- 4 Cooper C, Swanson N. Workplace violence in the health sector: state of the art.
place. Available at: http://www.cspsteam.org/education/education8.html/. Ac- Geneva, Switzerland: International Labour Office, 2002. Available at:
cessed June 19, 2008. http://icn.ch/state.pdf. Accessed June 19, 2008.
2 U.S. Department of Labor. Guidelines for Preventing Workplace Violence for 5 Massachusetts Nursing Association. Ten Actions A Nurse Should Take If
Health Care & Social Service Workers. Available at: http://www.osha.gov/Publica- Assaulted at Work. Available at:
tions/OSHA3148/osha3148.html. Accessed June 19, 2008. http://www.massnurses.org/health/articles/top_ten3.htm.
3 Carroll V. Preventing violence in the healthcare workplace. Alabama Nurse. Accessed June 19, 2008.
2004 Mar-May.

Joint Commission Targets Bullying


On July 9, 2008, The Joint Commission called for a crack- bullying among physicians, pharmacists, therapists, support
down on bullying among healthcare professionals, noting staff and administrators. Among those 11 steps:
that such behavior poses a serious threat to patient safety
and the overall quality of care. • Educate all healthcare team members about
professional behavior
In a press release titled “Joint Commission Alert: Stop Bad • Hold all team members accountable for modeling
Behavior among Health Care Professionals,” the group desirable behaviors, and enforce the code of conduct
announced it will be introducing new standards requiring consistently and equitably
more than 15,0000 accredited healthcare organizations to • Establish a comprehensive approach to addressing
create a code of conduct that defines acceptable and unac- intimidating and disruptive behaviors
ceptable behaviors. These organizations will also need to • Determine how and when disciplinary actions should begin
establish a formal process for managing unacceptable behavior. • Develop a system to detect and receive reports of
unprofessional behavior, and use non-confrontational
The Joint Commission is recommending that healthcare interaction strategies to address intimidating and
organizations take 11 specific steps to help put an end to disruptive behaviors

To view the press release in its entirety, please visit http://www.jointcommission.org/NewsRoom/NewsReleases/nr_07_09_08.htm.

56 The OR Connection
When one thinks of the operating room, phrases like
“cutting-edge technology,” “the future of medicine” and
“the newest procedures” come to mind. Although this is true,
comments like “This is how we have always done it” and “What?
Something new to learn?” are often heard as well. While these
barriers are hard to overcome, the OR of the future has many
champions, including Callie Craig, Team Manager and Periop-
erative Clinical Educator at INTEGRIS Baptist Medical
Center in Oklahoma City, Oklahoma.

Callie Craig: A Nurse Hero


By Megan Giovinco, RN, CNOR, RNFA
Callieʼs passion for perioperative nursing has been evident
throughout her eight-year tenure in surgery. She is very involved
in her facility as a member of numerous committees and councils
and was named INTEGRIS Surgery Department Nurse of the
Year in 2002.

Recruitment is one of Callieʼs primary concerns. Along with


serving as the co-chair of the Integris Nurse Recruitment and
Retention Team, she works with her facility in a variety of ways
to bring in new perioperative professionals. Callie is proud to
be a part of the many creative ways that INTEGRIS supports
both novice and experienced nurses.

As the departmentʼs educator, Callie has a great deal of


involvement with “next generation” nurses and works to

58 The OR Connection
Special Feature

Callie feels that the future of the


OR depends on all generations
of perioperative professionals
advocate the value they that it is just as important to
bring to the surgical arena. retain these perioperative

working together and learning


It was for these efforts that professionals as it is to
she was the recipient of recruit new ones.
AORNʼs Next Generation
Achievement Award at the from each other. Callie feels that the future of
55th Congress in Anaheim the OR depends on all
earlier this year. She was generations of periopera-
also elected to AORNʼs National Nominating Committee, for tive professionals working together and learning from each
which she pledges to “bring my passion for perioperative other: “The new nurses and techs bring the knowledge of their
nursing and the success of [AORN].” Her passions include recent education and the seasoned nurses have so much ex-
not only recruitment but the promotion of overall workplace perience to share. They need to get to know each other.” Cal-
safety, encouraging nurses to act as patient and professional lie encourages mentoring as a way for staff to learn from each
advocates and ensuring the continued growth of AORN. other. She credits her achievements to the support and coach-
ing she received from her own mentor, Janet Lewis, RN, MA,
Callie is certainly no new face to AORN. As a member of the CNOR, the Administrative Director of Surgical Services at IN-
Central Oklahoma Chapter of AORN since 2003, she has TEGRIS Baptist Medical Center. As a mentor to Callie, Janetʼs
attended Congress five times, three times as a delegate. She own passion for surgery was infectious. “She always said ʻcome
is also a member of the Educator/Clinical Nurse Specialist and with me – I will show you how,ʼ” Callie recalls.
Leadership Specialty Assemblies. She has served as both pres-
ident and vice president of her local chapter and as a part of Callieʼs passion for education and helping others spills over into
the membership and nominating committees. She is also other aspects of her life as well. She is a leader of Precept Upon
active in the Oklahoma State Council of Perioperative Nurses Precept Bible Study. She is also a member of the Council Road
and has served as their president. Baptist Church Womenʼs Council. She continues to help the
next generation as a community volunteer for the Junior League
Throughout her career, Callie has sought to improve her practice of Oklahoma City.
by continuing her education. She received her Certification for
Professional Achievement in Perioperative Nursing (CNOR) Callie has been known to quote Karen Kaiser Clark, who once
and earned her BSN from the University Of Arkansas Eleanor said, “Life is change. Growth is optional. Choose wisely.” Callie
Mann School Of Nursing. Recently, she received her masterʼs has certainly chosen to grow with the changes of her profes-
degree in Nursing Administration from the University of Okla- sion. She believes that the opportunities are infinite in todayʼs
homa Health Science Center. healthcare environment. She feels that the perioperative
professionalʼs reputation as the authority for patient and staff
Even though Callie is seen as an advocate for the next gener- safety must continue to expand as the challenges facing the
ation, she strongly believes that the “current generation” that medical community as a whole are addressed. Humbly, Callie
makes up part of the perioperative team has a great deal to hopes that she can be an example to other young nurses.
offer. Their experience and knowledge is invaluable to the staff There is no question that she is not only an example but also an
they work with and the patients for which they care. Callie feels inspiration to all perioperative professionals.

Aligning practice with policy to improve patient care 59


S.T.O.P. for Safety.

It could be the difference If you would like to receive a free sample


between life and death. of the S.T.O.P. Drape system to evaluate for
Wrong site surgery has recently moved into the yourself, ask your Medline representative or
number one position as the most frequently call us at 1-800-MEDLINE.
reported hospital error.1 STOP!!!
STOP!!!
Perform
P erform “TIME
“TIME O OUT”
UT”
This is despite a conscientious effort to eliminate this Verify
V erify ccorrect:
orrect:
problem before it occurs. What is needed is another layer Person
Person
Procedure
P rocedure
of safety...something that will improve our chances of Site
S ite & Side
S ide
correcting the mistake before it happens. Date:
Date: _______
_____ Time:
Time: ______
______
Surgeon’s
S urgeon’s Initials:
Initials: ______
____
Enter S.T.O.P. Surgical Drapes from Medline.
We just made a good idea even better. S.T.O.P. (Surgical
Time Out Procedure Drape) are available in a variety of
configurations, and include a “S.T.O.P.” strip* across the
fenestration. As a result, you can’t forget to take a time
out to verify the correct patient, procedure, side and site.
Then all that is left is to hand the sticker off to the circulating
nurse to include in the medical record, documenting that
the verification process was completed. S.T.O.P. strip and sticker

References
1 The Joint Commission. The Statistics page. Available at: http://www.jointcommission.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-

DDD11D43E484/0/SE_Stats_12_07.pdf. Accessed March 13, 2008.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Caring for Yourself

By Brian Tracy

The greatest obstacle to success The most common trap


The fear of failure is the single greatest obstacle to success in More than 99 percent of adults experience both these fears of
adult life. Taken to its extreme, we become totally preoccupied failure and rejection. They are caught in the trap of feeling,
with not making a mistake, with seeking for security above all “I canʼt,” but “I have to,” “I have to,” but “I canʼt.”
other considerations. The experience of the fear of failure is in
the words of “I canʼt,” “I canʼt.” We feel it in the front of the body, The key to peak performance
starting at the solar plexus and moving up to the rapid beating of The antidote to these fears is the development of courage,
the heart, rapid breathing and a tight throat. We also experience character and self-esteem. The opposite of fear is actually love,
this fear in the bladder and in the irresistible need to run to the self-love and self-respect. Acting with courage in a fearful situa-
bathroom. tion is simply a technique that boosts our regard for ourselves to
such a degree that our fears subside and lose their ability to
The fear of rejection holds you back affect our behavior and our decisions.
The second major fear that interferes with performance and
inhibits expression is the fear of rejection. We learn this when our Action exercises
parents make their love conditional upon our behavior. If we do Here are two things you can do to increase your self-esteem and
what pleases them, they give us love and approval. If we do some- self-confidence and overcome your fears.
thing they donʼt like, they withdraw their love and approval – First, realize and accept that you can do anything you put your
which we interpret as rejection. mind to. Repeat the words, “I can do it! I can do it!” whenever you
feel afraid for any reason.
The roots of a Type A behavior Second, continually think of yourself as a valuable and important
As adults, people raised with conditional love become preoc- person and remember that temporary failure is the way you learn
cupied with the opinions of others. Many men develop Type how to succeed.
A behavior that is characterized by hostility, suspicion and an
obsession with performance to some undetermined high stan- Reprinted with permission from www.mercola.com.

dard. This is expressed in the attitude of “I have to,”


“I have to,” and is associated with the
feeling that “I have to work harder and
accomplish more in order to please
the boss” who has become
a surrogate parent.

Aligning practice with policy to improve patient care 61


How to Thrive in
a Tough Economy
Unless you are on another planet, it is likely that your organization has already gone
through several “downsizings” or “rightsizings,” as your boss might like to call them.
Time to get depressed, right? Wrong!

By Wolf J. Rinke, PhD, RD, CSP

62 The OR Connection
Special Feature

and financial officer would fit into this category. Next are the
project managers. They are responsible for making sure
that the talent and resources are organized in such a way
that the project gets done. Next is the talent. These are the
people who have the skills to get the job done, such as
nurses, OR techs and other front-line healthcare profes-
sionals. To thrive in this tough economy, it is important that
you master “winning management” skills so that you can
perform equally well in the project manager or resource
provider role. (For details read my Winning Management:
6 Fail-Safe Strategies for Building High-Performance
Organizations book.)

Think global
Globalization is accelerating at a nanosecond pace. To take
advantage of globalization, you must dramatically increase
your cultural awareness. If you are now employed in a
primarily “homogeneous” organization and are not at least
90 percent satisfied, seek employment in a multicultural
organization. Donʼt know where to start? Get a copy of
Time to put yourself in the driverʼs seat of your career by Fortuneʼs latest issue of either 100 Best Companies to Work
developing new skills that will enable you to take advantage For (typically published in February) or Americaʼs Most
of the opportunities that are unfolding before your very Admired Companies (typically issued in March of every
eyes – opportunities that will enable you to not only survive, year) and apply to any of the companies listed. Want to stay
but thrive in this tough economy. in health care? Not a problem, there are many on either list.
For example, Methodist Hospital System is in the number
Think projects 10 spot on the 2008 100 Best Companies to Work For and
Old organizations were organized by departments and Manor Care is in the number one spot for the Healthcare
position titles. Today, projects accomplish most work. To Medical Facilities Group in the 2008 Americaʼs Most
thrive in a project environment, recognize that work gets Admired Companies.
done primarily by three distinct specialties. First, there are
the resource providers. These are the folks who develop Equally important, learn a foreign language. If youʼre not
and supply talent or money. Your human resource manager fluent in at least one foreign language, you will be in trouble

Aligning practice with policy to improve patient care 63


IN THIS TOUGH ECONOMY
real soon. And put your language you can simply no longer expect to be Think of yourself
to work by traveling to a country compensated for time, only for results as self-employed
that speaks the language of in- Seeing yourself working for
terest to you. Youʼll really learn to and problems solved. one company for the rest of
speak it, become culturally sen- your career is, to say it gently,
sitive whether you want to or not crazy! Itʼs just not going to
and will bring back a ton of great ideas to accelerate your happen! In this tough economy, itʼs important that you see
success curve dramatically. yourself as “self-employed,” or “renting” your services out
to someone else (your employer). To get started, pretend
Become an effective team player and leader that you are an entrepreneur or a consultant who is selling
Like it or not, teams are the way lots of work is being services to a client (your employer). To make this realistic,
accomplished in todayʼs organizations. Being effective in compute your daily compensation. Be sure to add about 30
this environment requires that you learn how to empower percent for benefits. Then get in the habit of asking yourself
others and master leadership and winning management “Have I created value today that exceeded my daily com-
skills, and be equally comfortable and effective in a pensation?” Repeat that question every day you are at
supportive role as in a leadership role. (For more, read my work. You may even find it helpful to place a nice-looking
Donʼt Oil the Squeaky Wheel and 19 Other Contrarian Ways sign on your work station that asks “How are you creating
to Improve Your Leadership Effectiveness book.) $_____ of value today?”

Focus on delivering exceptional quality service The other side of the coin is to keep asking “How have I
Delivering exceptional quality service is not an option, but ʻgrownʼ in my job today?” To make this happen, think of
rather a survival strategy. We must be absolutely clear going to work each day with a “briefcase” of skills and com-
about who provides us with our paycheck. No, itʼs not your petencies. At the end of the day, check your briefcase to see
boss or even your organization. It is the person you serve – if there is more in it than at the beginning of the day. If, day
an external or internal “customer.” As a litmus test of how after day, what you bring to work is the same as what
customer-focused you are, look back at your calendar for you take home, itʼs is time to move on to a more challeng-
the last week to find our how much actual time youʼve spent ing “assignment.”
with your external or internal customers. If you are not
spending at least one third of your time with your “cus-
tomers,” you are messing up.
Get in the habit of asking yourself,

Become a problem solver


“Have I created value today that
One of the best ways to position yourself for advancement
exceeded my daily compensation?”
or pay increases is to become a problem solver. In this Become an expert networker
tough economy, you can simply no longer expect to be com- One of the most powerful skills you can develop is to
pensated for time, only for results and problems solved. So become a highly effective networker, both inside and outside
actively look for a problem that impacts negatively on the of your organization. When it comes time to find a new
bottom line then put a team together and solve it. Then, let assignment, your network, more than anything else, will
others know (especially the powers-that-be) what a great determine how fast youʼll find your next dream job. To test
job your team did and how much your team improved the your networking effectiveness, ask yourself who you have
profitability of your organization. If you do that consistently, been eating lunch with during the past week. If it is pretty
you will be ready to be promoted or negotiate for an much the same people, you are missing tremendous net-
increase in pay. (If youʼd like help with that, devour my working opportunities. Get in the habit of eating lunch with
Win-Win Negotiation CPE program.)

64 The OR Connection
different people three out of five days a week, to sit with people
you donʼt know at meetings and to attend conferences that
are sponsored by groups other than yours.

Check yourself
To assess how well you are achieving a competitive advantage
in this tough economy, ask yourself the following diagnostic
questions:
ASK YOURSELF...
Am I learning?
If you are not constantly learning new things, your value in
• Am I learning?
the marketplace is diminishing rapidly. • Am I being taken advantage of?
Am I being taken advantage of?
• If my job was open today,
Your employer is taking advantage of you if you consistently would I get it?
sacrifice your long-term development to put out short-term
“fires.” Donʼt let your ego get the better of you when you are
• Am I adding value?
being told that you are so critical to the organization that “we • Am I good at selling?
canʼt do without you.” Hogwash! No one is indispensable.
Never, ever get caught in persistent short-term traps at the
• Am I energized by change?
expense of your long-term development. • Does my résumé focus
If my job was open today, would I get it?
on contributions?
Itʼs important that you “benchmark” your skills all of the time.
Continued on Page 36

Aligning practice with policy to improve patient care 65


Small in size.
Big on safety.

Sometimes smaller is better! The transthermal backing on 9100 Series electrosurgical pads
provides a barrier of moisture; it is waterproof and fluid resist-
At just 15 square inches, the Medline Universal Pad with propri-
ant. The backing allows heat to escape 25% faster than the
etary Safety Ring meets the same thermal performance stan-
foam traditionally used on grounding pads, reducing the risk of
dard as traditional electrosurgical pads up to 33% larger in
excessive heat buildup.
conductive surface area.

For more information on the impact the Universal


Despite its smaller size, this pad is big on safety. The propri-
Pad 9100 Series can have in your OR, contact your
etary Safety Ring allows the pad to be oriented in any direction
Medline sales representative or call 1-800-MEDLINE.
and also reduces corner and edge effect by more uniformly dis-
persing electrosurgical current over the entire conductive
surface of the pad.
Electrosurgical Pad
9100 Series

Manufactured by 3M
Medical Division
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
One way to do that is to look at the want ads to find out what liberate and empower you. Action will get you to grow,
the marketplace is looking for. If you do not possess the change and adapt. Action will provide you with virtual job
skills that the marketplace is looking for, itʼs time to invest security, will enable you to achieve the competitive advan-
more in yourself. tage and assure that you thrive in this tough economy.

Am I adding value?
How long does it take you to answer this question? If you
are unable to answer it immediately, in fewer than two or
three sentences, you can assume that no one else knows
how you contribute value either. In that case, you are a likely
target during the next downsizing.

Am I good at selling?
Many healthcare professionals see no need to become About the author
excellent at selling. The reality is that you sell all the time. Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar
You sell your patient on getting better, you sell your boss on leader, management consultant, executive coach and editor
a raise and you sell your team members on an idea. In of the free electronic newsletters Make It a Winning
addition, you do the same at home with your spouse, children Life and The Winning Manager. To subscribe, go to
and even your pets. Since it is something you do all of www.WolfRinke.com. He is the author of numerous books,
the time, I recommend that you get good at it. No, wait, I CDs and DVDs including Winning Management: 6 Fail-Safe
recommend you get great at it! So start looking for a quality Strategies for Building High-Performance Organizations and
sales program and attend it this year! Donʼt Oil the Squeaky Wheel and 19 Other Contrarian
Ways to Improve Your Leadership Effectiveness, available
Am I energized by change? at www.WolfRinke.com. His company also produces a wide
If you are still fighting or resisting change, you are in trouble. variety of quality pre-approved continuing professional
All indications are that change will continue to accelerate at education (CPE) self-study courses available at www.easy
“hyper speed,” so you might as well start welcoming it. CPEcredits.com. Reach him at WolfRinke@aol.com.

Does my résumé focus on contributions?


Finally, to check how focused you are on contributions, get
out your résumé and check for specific outcomes, specific
impact on the organization and variety and content of work,
projects and leadership experiences. Are you impressed?
Would you hire this person? If so, congratulations!

The most important concept


of all time: Take action
There is one more skill that you need to master. This one is
more important than all the others. Itʼs the one skill that,
when all else fails, will determine whether you will thrive in
this tough economy. The skill is to take action! Action lets
you know whether what youʼve tried works. If it does, do
more of it. If it does not, try something else and start the
same process all over again. Soon youʼll find yourself suc-
ceeding faster than you have ever thought possible. And
whatever you do, avoid fretting about having failed – there
is no such thing, unless you make the same mistake over
and over again. Action gets you away from bemoaning
change and mourning the lack of job security. Action will

Aligning practice with policy to improve patient care 67


Special Feature

Angel’s Passion for Pink


By Laura Kuhn
The OR Connection staff writer

Angel hummed to herself as she tacked a poster on the the cause. She planned to reveal that at the meeting the
hospitalʼs bulletin board. She heard footsteps approaching next day.
and turned to see her coworker Mary peering over her shoulder
at the poster. Thanks to Angelʼs posters and word of mouth, the meeting
room was filled to capacity. True to her word, Mary arrived
“Whatʼs that, Angel?” Mary asked. “Itʼs pretty. I like the pink bearing a tray of cookies. At the podium in the front of the
ribbons. They match the ribbon on your lab coat!” room, Angel was nervously shuffling a stack of note cards.
She had written down what she planned to say, but as her
“Iʼm hosting a meeting for staff members to remind them how coworkers took their seats and started looking expectantly at
important it is to conduct monthly breast self-exams,” Angel her, she decided to place her notes in her pocket and simply
explained. “Can I count on you to be there?” speak from her heart.

“You bet!” Mary replied. “Iʼll even bring some cookies.” She “Hi, Iʼm Angel, and I know most of you,” she said. “You might
headed off down the hall to visit her next patient. have noticed that I spend a lot of time promoting education
about breast cancer, and encouraging you to do monthly self-
Angel smiled as she smoothed out the corners of the poster. exams. What you might not know is why I care so much.” She
She was known for tirelessly campaigning for breast cancer took a deep breath and steadied her voice.
education, but very few people knew what had drawn her to

68 The OR Connection
“When I was a sophomore in college, my mother was diag- “But thereʼs good news, too,” she continued. “Today, some-
nosed with breast cancer. I spent the next six months, what one who is diagnosed with breast cancer in its earliest stages
were ultimately the last six months of my motherʼs life, at her has a 98 percent chance of living. That rate was only 77
side. I was there when she was wheeled out of surgery after percent in 1982. And education is helping to emphasize the
a double mastectomy. I was there when chemo caused her importance of screening, early education and the need for
beautiful hair to fall out all over her pillow. And I was there more research.”
when she admitted to her doctor that she had never done a
breast self-exam. Angel grabbed for the stack of pamphlets she had brought
with her and began to hand them out. “These tell you how to
“My mother didnʼt know how to perform a self-exam, and she perform a breast self-exam and give you more information
wasnʼt comfortable with the idea. She didnʼt know that there on ways you can help spread the word,” she said. “Please,
could be outward signs of breast cancer, such as change in take a bunch of them! Give them to your friends, your family,
the size or shape of the nipple. She didnʼt know that dimpling your patients.” She was encouraged to see that the members
or puckering could be signs of an underlying problem. of the audience were taking four or fivepamphlets as they
were passed along.
“My mom didnʼt know these things, just as a lot of people
donʼt understand the full scope of how serious a problem She made her way back up to the front of the room to finish
breast cancer still is. Weʼre making advances in early detec- speaking. “Thank you so much for coming to this meeting. I
tion and treatment, but this disease is by no means going lost my mother to breast cancer, and Iʼll miss her every day
away. In fact, more than 1.1 million women throughout the of my life. With your help, though, we can prevent someone
world will be diagnosed with breast cancer this year, and else from experiencing that same agony. Education is truly
more than 410,000 of those women will die.” the key. Together, we can save lives through early detection.”

Angel looked around the room and saw that the faces of Angel smiled and was thrilled to see smiling faces looking
many audience members had turned grim. She needed to back at her.
inspire them, and fast!

Stay tuned for the continued adventures


of Medline’s family of nurse dolls, Angel,
Aurora, Anastasia, Ami and Alice!

Alice Aurora Anastasia Ami

Aligning practice with policy to improve patient care 69


The
choice
is yours
Medline’s comprehensive line of facemasks was de-
signed to meet a variety of needs and preferences,
but all of our masks are united by a common trait—
quality. Every mask we manufacture—from our fluid-
resistant masks to our spearmint-scented masks—is
backed by Medline’s quality guarantee and designed
to exceed expectations for comfort and protection.

• Fluid resistant
• Fog free
• Spearmint scented
• Chamber style
• Isolation
• Procedure
• Face shield
• Protective eyewear

For more information on Medline


facemasks, please contact your
Medline sales representative or call
1-800-MEDLINE.

©2008 Medline Industries, Inc. www.medline.com


Medline is a registered trademark of Medline Industries, Inc.
Caring for Yourself

Medline Supports Breast Cancer


Awareness 365 Days a Year
Together We Can Save Lives Through
Early Detection Breast Cancer Campaign

Every three minutes a woman in the United States is Beyond the Shock® DVD
diagnosed with breast cancer. The chance of developing Medline, in partnership with the NBCF, distributes free
invasive breast cancer at some time in a woman's life is copies of the DVD “Beyond the Shock,” a step-by-step guide
about 1 in 8.¹ These are startling statistics, but behind these to understanding the diagnosis of breast cancer. More than
numbers are people — sisters, daughters, mothers, grand- 70 leading oncologists contributed to the content. To request
mothers, neighbors and friends. Any one of the 182,460 a copy, contact Jennifer Freedman at (847) 643-4358 or
women who will be diagnosed with invasive breast cancer jfreedman@medline.com.
this year could be someone we love. Although mammo-
grams are among the best forms of early detection, more Angel doll
than 13 million American women over the age of 40 have Angel, the second-born in Medlineʼs family of nurse dolls,
never had one.2 The Centers for Disease Control recommend promotes infection prevention and she also sports pink
that women begin having yearly mammograms at age 40. scrubs and a pink ribbon to support breast cancer awareness.
The Angel doll is distributed by Medline at trade shows and
These facts form the foundation of Medlineʼs “Together We large customer events.
Can Save Lives through Early Detection” campaign. Medline
is on a mission to change the future by taking action now. Pink ribbon products
2008 marks the third year that Medline has partnered with Medline sells several pink ribbon products, including a
the National Breast Cancer Foundation (NBCF), which Breast Cancer Awareness Rollator and bath bench, a pink
provides grants to hospitals and healthcare organizations ribbon lab coat and special scrubs available on
that offer free mammograms for underprivileged women. To scrubs123.com. A customerʼs purchase of these products
date, Medline has donated $350,000 to the NBCF to give supports Medlineʼs partnership with the NBCF. Visit
back to customers and their communities, help promote medline.com or scrub123.com or contact your Medline
early detection of breast cancer and ultimately save lives. sales representative for more information.

Spreading the word For more information on Medlineʼs breast cancer


To keep early detection on everyoneʼs minds, Medline awareness campaign, visit www.medline.com/bca
sponsors a number of outreach projects throughout the or contact Jennifer Freedman at 847-643-4358 or
year and distributes several products and programs to jfreedman@medline.com
promote awareness.

AORN breakfast forum References:


1. American Cancer Society. Cancer Reference Information. “What Are the Key
In March, Medline hosted a breakfast forum for 900 periop- Statistics for Breast Cancer?” Available at: http://www.cancer.org/docroot/
erative nurses at the annual meeting of the Association of CRI/content/CRI_2_4_ 1X_What_are_the_key_statistics_for_breast_cancer_ 5.asp.
Accessed July 15, 2008.
periOperative Registered Nurses (AORN) in Anaheim, Calif. 2. The Breast Cancer Site. About Breast Cancer page. Available at:
Featured speaker, Dr. Marla Shapiro, author of Life in the http://www.thebreastcancersite.com/clickToGive/boutbreastcancer.faces?siteId
Balance: My Journey with Breast Cancer and renowned
=2&link=ctg_bcs_aboutbreastcancer_from_home_maincolumn.

Canadian on-air medical expert, delivered a dynamic pres-


entation on coping with stress, balancing life and battling
breast cancer. Visit www.medline.com/aorn/2008 to learn
more about the event.

Aligning practice with policy to improve patient care 71


Caring for Yourself

Ease the Discomfort of PMS


You're feeling bloated and irritable all at the same time. Sound familiar?
You're probably having premenstrual syndrome (PMS). Up to 85 percent of
menstruating women have at least one PMS symptom as part of their
monthly cycle, according to the American College of Obstetrics
and Gynecologists.

The emotional and physical symptoms, which usually occur in the week or
two before your period, can range from mild to severe. Symptoms vary from
person to person and may include:

• Irritability or mood swings


• Tension or anxiety
• Acne
• Breast swelling and tenderness
• Tiredness
• Insomnia
• Bloating
• Depression
• Digestive problems
• Headaches
• Joint or muscle pain

Often, symptoms go away after your period starts.

Try these tips


If you think you have PMS but want to find out for sure, keep track of your
symptoms on a calendar for a couple of months. Note their severity and the
date your period starts. Then, show your doctor the calendar and your notes.

The cause of PMS remains unclear, but you may be able to ease symptoms
by following these self-care tips from the U.S. Department of Health and
Human Services:

• Take a daily multivitamin with 400 micrograms of folic acid and a


calcium supplement with vitamin D.
• Exercise regularly. For safety's sake, first check with your doctor.
• Eat a healthful diet that includes plenty of fruits, vegetables and
whole grains.
• Avoid salt, sugary foods, caffeine and alcohol.
• Try to get eight hours of sleep every night.
• Don't smoke.

Lifestyle changes alone may not bring relief if you have severe symptoms.
If this is the case, your doctor may suggest an over-the-counter pain
reliever or other medicines.

Reprinted with permission from United Healthcare

72 The OR Connection
Healthy Eating

Holy Guacamole!
You can make this avocado salad smooth
or chunky depending on your preference.

Nutritional Information
Prep time 10 minutes Servings Per Recipe: 4
Guacamole (4 servings)

Ready in 10 minutes Amount Per Serving


Calories: 264
3 avocados - peeled, pitted and mashed Total Fat: 23.3g
1 lime, juiced Cholesterol: 0mg
1 teaspoon salt Sodium: 601mg
1/2 cup diced onion Total Carbs: 16.4g
3 tablespoons chopped fresh cilantro Dietary Fiber: 8.8g
2 roma (plum) tomatoes, diced Protein: 3.7g
1 teaspoon minced garlic
1 pinch ground cayenne pepper (optional)
www. allrecipes.com
In a medium bowl, mash together the avocados, lime juice
and salt. Mix in onion, cilantro, tomatoes and garlic. Stir in
cayenne pepper. Refrigerate 1 hour for best flavor, or serve
immediately.

Aligning practice with policy to improve patient care 73


Customized solutions.

Anesthesia Supply
Management Solutions
Does your anesthesia storage need help? When you part-
ner with Medline, your anesthesia supply management
world will be revolutionized.

With Anesthesia Complete Delivery System (ACDS*), all


anesthesia supplies will be par level packaged in a stan-
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staff to order, receive and stock shelf supplies.

Taking care of your needs every step of the way


Each program is custom designed based on your facility’s
anesthesia supply requirements. Medline’s® ACDS will …
• Increase staff productivity and satisfaction
• Improve inventory control
• Increase space utilization
• Improve charge/cost capture
• Eliminate outdated product For your free cost-savings analysis,
• Enhance supply standardization contact your sales representative or
• Enhance compliance with JCAHO, AORN and SCIP call 1-800-MEDLINE.

* Patent pending

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
FORMS & TOOLS

The following pages contain practical tools for implementing


patient-focused care practices at your facility.

Electrosurgery
Electrosurgery Checklist..............................76
Electrosurgical Cautery Safety
Policy and Procedure ..................................78

Policy and Procedure ..................................81


Pressure Ulcer Prevention

Patient Safety
Surgical Safety Checklist........................86

Employee Safety
Management/Employee Checklist ..........89
Employee Incident Report ......................90

Aligning practice with policy to improve patient care 75


Forms & Tools Electrosurgery Checklist 1

Electrosurgery Checklist
Preoperative Precautions and Procedures  Do not overlap sections of the electrode (e.g., when
applying around a small limb).
Physical Condition  When possible, place a long edge of the electrode
 Examine the ESU and its accessories for defects— closest to the surgical site.
do not use cables or accessories with damaged  If possible, do not place the dispersive electrode (or
(cracked, burned, or taped) insulation or connectors. active electrode) cables near internal pacemaker leads.
 Confirm that the ESU has been inspected for safety
and performance by a qualified BMET or clinical Alternate Sites
engineer and that the next inspection is not yet due.  Eliminate patient contact with grounded objects
whenever possible.
Return Electrode Contact Quality Monitor  If possible, remove nonvital monitoring electrodes
(RECQM) or Cable Continuity Alarm (e.g., esophageal and rectal probes).
 Check the operation of the RECQM or the return  Keep ECG and other monitoring electrodes as far
electrode cable continuity alarm by attempting to as possible from the surgical site and the active and
operate the unit with the dispersive electrode dispersive electrode cables.
disconnected—the unit should not activate, and a  Do not use needles as monitoring electrodes (these
tone should sound. increase the risk of alternate site burns due to higher
current density at the electrode site).
Audible Activation Indicator
 Activate the unit using each footswitch and Prepping Agents
handswitch, and verify that the audible activation  Avoid using flammable prepping agents or other
tone is loud enough to be heard over other noises in flammable fluids (e.g., acetone degreaser).
the OR.  Avoid accumulating pools of fluids, especially near
 Verify operation of any other alarms or patient electrodes.
protective features.
Sparking the Active Electrode
Safety Holster  Do not spark the active electrode to ground or to the
 Position a safety holster for the active electrode in a dispersive electrode to test the ESU.
convenient location.
Intraoperative Precautions and Procedures
Dispersive Electrode
 Use a full-surface adhesive electrode.  Minimize buildup of O2 and N2O beneath drapes and
 Inspect the electrode before placement for any flaws in the oropharynx.
or damage (e.g., discoloration, insufficient amounts  Activate the unit after vapors from flammable prepping
of conductive adhesive). solutions and tinctures (if used) have dissipated.
 Confirm that the electrode's expiration date has  Activate the unit only when ready to deliver electrosur-
not passed. gical current and only when the active tip is in view;
 Clean, shave, and dry the application site. avoid prolonged activation.
 Follow the manufacturer's recommendations for appli-  Use the lowest effective ESU output setting; do not
cation, and ensure firm contact of the electrode with continue to increase power settings if you aren't
the skin. getting results—look for other problems (e.g., confirm
 Do not apply the electrode to areas where pressure is adequate placement of the dispersive electrode,
applied to the patient (e.g., underneath the patient). check all cable connections).

76 The OR Connection
Electrosurgery Checklist 1 Forms & Tools

 Check contact and adherence of the dispersive


electrode each time the patient is repositioned. Regarding “Checklists...”
 Always place the active electrode in a safety holster
when not in use. Worldwide, the WHO aims to have the checklist oper-
 Allow only the user of the active electrode to activate
ating in 2,500 hospitals in the most populous countries
the handswitch or footswitch.
(with 75 per cent of the world's population) by the end
 Do not use two active electrodes on ESUs that
of next year.
produce simultaneous activation of both electrodes
when only one switch is activated.
 Document every procedure in the OR record; include
Since the 1930s, airplane pilots have run through
the ESU identification number, ESU settings used checklists before taking off. Now the World Health
(monopolar cutting and coagulation, bipolar), location Organization wants surgeons all over the globe to use
of the dispersive electrode, and the condition of the them, too.
skin at the dispersive electrode site before and after
the procedure. Dr. E. Patchen Dellinger, a surgeon at the University of
 Document use and position of any other equipment Washington Medical Center in Seattle, says people
(including identification numbers) used during the are surprised when he tells them about the project.
procedure (e.g., hypo-/hyperthermia unit, tempera- "One of the common reactions is, 'You mean you
ture probes). weren't doing that before? Good heavens!'"
he says.
Postoperative Precautions and Procedures

 Inspect the patient for injuries at the dispersive Gawande says there's been some resistance to the
electrode and other sites (e.g., the sacral area— list. One London surgeon thought it was demeaning
electrosurgical injuries typically appear immediately "Mickey Mouse stuff" until one day in the operat-
following the procedure; pressure injuries may not ing room.
show up for as long as one or two days following
surgery). "Right before the incision [the medical team] took a
 Document all findings. timeout," Gawande says, "and when it came to the
 If any problems are noted during or after the nurse's turn to raise any concerns, the nurse asked:
procedure, save all disposable items and their
'Are we really sure we have the right size knee
packages (so that expiration dates can be confirmed).
replacement for this patient?'"
Turns out, they didn't — not anywhere in the hospital.
Courtesy of Medical Device Safety Report (MDSR) ECRI Institute, 2008.
That surgeon now swears by the surgical checklist.

Aligning practice with policy to improve patient care 77


Forms & Tools Policy and Procedure

Electrosurgical Cautery Safety


PURPOSE: – Before each electrosurgical unit use, the operative
To provide for the safe operation of electrosurgical units, used field shall be inspected for alternate ground points.
for the purpose of cutting and coagulation of body tissue with Personnel and/or patients may be injured, if the
a high frequency electrical current during surgical procedures. current does not follow the designated path. Isolated
patient EKG lead units shall be used. The patient
EQUIPMENT: shall not be in contact with metal table parts.
 Electrosurgical Generator – The patient's skin integrity shall be evaluated before
 Electrosurgical Grounding Pad and after electrosurgical use. Particular areas to
 Electrosurgical Active Electrode (Pencil) observe are under the electrode, under EKG leads,
temperature probe entry sites and positional
POLICY: pressure points.
 All electrosurgical generators shall meet the – The dispersive electrode, cord and pad, and the
performance and safety standards of the hospital. active electrode and cord shall be retained for use
– All electrosurgical units must be approved by the during the investigation of an adverse post-op
hospital Biomed. skin reaction.
– Only electrosurgical units which are UL approved
shall be used in the operating room.  The Electrosurgical Ground Pad
– Surgical Services personnel are provided with (Dispersive Electrode):
detailed instructions from the electrosurgical unit's – Only disposable dispersive electrodes evaluated
manufacturer. Operational directions are attached by the hospital Biomedical Engineer, are to be
to each electrosurgical unit. used in the Surgical Services Department.
– Surgical Services personnel are evaluated annually – The dispersive electrode shall be inspected before
on the safe competency form use of the each use for wire breakage or fraying. All connec-
electrosurgical unit and its components. tions shall be intact and clean.
– The electrosurgical unit generator is inspected – The dispersive electrode shall be long enough and
yearly by the hospital Biomed. Dates of inspection flexible enough to be placed on the patient without
are posted on units. Each electrosurgical unit stress on any connection.
generator is assigned an ID number. – The dispersive electrode cord shall fasten directly
– The electrosurgical unit is properly grounded, into a labeled, stress-resistant receptacle on the
mounted on a stand, easily cleaned and movable. electrosurgical unit.
– The electrosurgical unit generator shall be kept – The dispersive electrode pad shall be placed on
clean and protected from spills. the patient, on clean dry skin over a large muscle
– The electrosurgical unit footswitch shall be designed mass, as close to the operative site as possible.
for easy cleaning, shall be shock-resistant and Bony prominences, hairy surfaces, and scar tissue
designed to minimize unintentional activation. shall be avoided.
– The electrosurgical unit footswitch cord shall be long – Do not put the dispersive electrode pad over a
enough to reach the user without stress. patient's tattoo.
– Before each use, the electrical cord, connections, – Do not put the dispersive electrode pad on the
plug and foot switch cord shall be inspected for patient's skin over a metal prosthesis.
damage. The unit shall be removed from service
if damaged. Dispersive electrode and placement which restricts
– Before each use, the electrosurgical unit safety blood flow shall be avoided.
features (lights, activation sound, etc.) shall – All dispersive pads shall maintain uniform body
be tested. contact. Potential problems include tenting, gaping
– Power settings for coagulation and/or cutting shall and liquids interfering with adhesion.
be as low as possible for each procedure, confirmed – Use pediatric electrosurgical ground pad according
orally with the surgeon before activation and to weight limit.
determined according to manufacturer recommen- – The pad placement area shall be charted on the
dation. Activation tones are not to be turned off or Intraoperative Nursing Record and Nurses' Notes.
adjusted to a lower setting. (The activation tone on
newer models cannot be turned off or adjusted.)

78 The OR Connection
Policy and Procedure Forms & Tools

 The Electrosurgical Active Electrode (Pencil): Based upon the policy and procedure used at Stonewall
– Only electrosurgical active electrodes approved by Jackson Memorial Hospital in Lewis County, West Virginia.
the hospital Biomedical Engineer are to be used in
the Surgical Services Department.
– The active electrode shall be inspected at the field
for damage before each use.
– The active electrode shall fasten directly into a
labeled, stress-resistant receptacle on the
electrosurgical unit.
– The active electrode cord shall be long enough
and flexible enough to reach the operative site and
the generator without stress.
– The active electrode cord shall be free of loops,
twists and metal clamps that can deviate
current flow.
– The active electrode and cord shall be inpervious
to fluids.
– The active electrode tip shall be secure and free of
charred tissue. Use a moist sponge to clean
the tip.
– The active electrode will be placed in a holster at
all times, when not in use.

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Pressure Ulcer Prevention Policy and Procedure Forms & Tools

Pressure Ulcer Prevention


Personnel: All accountable for patient care
Patient outcomes:
1. Maintenance of intact skin in the patient who is at risk for breakdown.
2. Patient/caregivers verbalize knowledge of pressure ulcer risk factors, assessment,
prevention and early treatment.

High Risk Diagnoses: Factors That Contribute To Pressure


Ulcer Development

 Peripheral Vascular Disease  Age greater than 75


 Myocardial Infarction  Existing pressure ulcer
 Stroke  Immobility
 Multiple Trauma  Those having a procedure
 Musculoskeletal which immobilizes them for
disorders/Fractures greater than one hour
 GI Bleed  Bed linen
 Spinal Cord Injury  Devices (e.g., oxygen tubing,
 Paraplegia splints, TEDs stockings)
 Neurological disorders (e.g.,  Sedation
Guillain Barré, multiple  Sensory deficits
sclerosis)  Nutritional deficits/Weight loss
 Those with unstable and/or  Excessive exposure to
chronic medical conditions (e.g., moisture (e.g., incontinence,
diabetes, renal disease, cancer) excessive perspiration, wound
 History of previous pressure drainage)
ulcer  Those exposed to friction and
 Preterm neonates shearing

Early and ongoing assessment of patients at risk for skin breakdown is essential.
Prevention involves not only identification of patients at risk but also a detailed plan
of interventions which address and minimize the effects of each risk factor.

Aligning practice with policy to improve patient care 81


Forms & Tools Pressure Ulcer Prevention Policy and Procedure

Nursing Diagnosis

Asessement/evaluation Interventions/key points

1. Identify patients at risk for developing a 1. Determine an adult patient's risk for
pressure ulcer upon admission and daily for developing a pressure ulcer by using the
at-risk patients or with any change in condition. Braden Risk Assessment.
A patient is considered at risk if their
Braden score is:
15-18 = Mild risk
13-14 = Moderate risk
10-12 = High risk
9 or below = Very high risk
2. Advance your patient to the next risk level in
the presence of:
A. Age over 75
B. Chronic illness
C. Hemodynamic instability (e.g., diastolic
blood pressure less than 60 mmHg).
3. Utilize the Nursing Care Plan to individualize
specific prevention interventions.
4. Initiate Pressure Ulcer Treatment Protocol at
the first sign of skin breakdown.
5. Consult WOC nurse when current plan of
care does not meet the needs of the patient.

2. Assess specific vulnerable pressure points. 2. Inspect the skin at least every 8 hours.
A. Supine: occiput, sacrum, heels A. Avoid vigorous massage over bony
B. Sitting: ischial tuberosities, coccyx prominences.
C. Side-lying position: trochanters B. Patients with dark pigmentation will
D. Reddened areas which do not fade within demonstrate a cyanotic area, warmth or
30 minutes complain of pain over the bony prominence.
E. Dusky or cyanotic areas
F. Under devices (i.e., TEDs, pneumoboots,
splints, collars, tubing)

3. Assess skin for exposure to moisture from 3. Cleanse and dry skin at routine intervals or
intervals incontinence, wound drainage and at the time of soiling, using a low residue soap.
perspiration. A. Initiate the Incontinence Protocol in the
incontinent patient.
B. Moisturize dry skin with lotion.

82 The OR Connection
Pressure Ulcer Prevention Policy and Procedure Forms & Tools

Nursing Diagnosis
4. A. Assess mobility and activity status. 4. A. 1. Maintain or increase patient's level of
activity, mobility and range of motion unless
B. Identify sitting status. contraindicated.
2. Schedule regular and frequent turning and
repositioning at least every 2 hours (e.g.,
alternating supine, left lateral and right lateral
positions).
3. Individualize to the patient's needs based
on risk and level of mobility.
B. For sitting position in bed (head of bed
greater than 30°), cardiac chair or wheelchair:
1. Assist/instruct patient to shift weight at
least every 15 minutes.
2. Reposition at least every 30 minutes if
patient cannot independently perform
pressure relief exercises every 15 minutes.
3. Consult PT/OT for assistance in seating,
positioning and wheelchair cushion options.

5. Assess nutritional status. 5. Due to increased protein needs for healing,


consult Nutrition Services for a nutritional
assessment and plan at the earliest sign of
skin breakdown.

6. Identify factors that increase shearing, fric- 6. A. 1. Keep head of bed less than 30° unless
tion and/or pressure. contraindicated.
A. Shearing: Tissue layers sliding against each 2. Promote proper positioning, transferring and
other; e.g., sliding down in bed. turning techniques.
B. Friction: Skin rubbing against other sur- B. 1. Use reusable underpad, trapeze or lift
faces; e.g., elbows and heels rubbing against sheet to lift, not drag, patient.
sheets. 2. Utilize pillows or positioning devices to
C. Pressure/friction: e.g., heels resting on mat- prevent skin surfaces from rubbing together.
tress, devices such as oxygen tubing, cervical C. 1. The immobilized patient should have heels
collars, casts. suspended off bed by using pillows or heel
suspension boots.
2. Heel and elbow protectors are best used for
reducing friction and should not be used for
pressure reduction.
3. Pad devices when it is not contraindicated.

Aligning practice with policy to improve patient care 83


Forms & Tools Pressure Ulcer Prevention Policy and Procedure

Nursing Diagnosis
7. Assess patient/family knowledge of pressure 7. A. Teach patient/family about the causes and
ulcer prevention, risk factors and early treatment. risk factors for pressure ulcer development and
ways to minimize risk.
B. The patient or caregiver, or both, should
understand the importance of the following:
1. Conduct regular inspection of skin over bony
prominences. (Individuals can use a mirror if
necessary to inspect their own skin.)
2. Follow appropriate skincare regimens.
3. Use measures to reduce friction/shearing.
4. Avoid vigorous massage of bony prominences
or reddened area.
5. Include routine turning, repositioning and the
use of pressure-reducing devices if patient is
confined to bed and/or chair.
6. Avoid use of donut-type devices.
7. Maintain adequate nutrition and fluid intake
and monitoring for weight loss, poor appetite or
gastrointestinal changes that interfere with eating.
8. Program for bowel and bladder management.
9. Promptly report healthcare changes and
nutritional problems to healthcare providers.

Adapted from North Memorial Health Care’s Pressure Ulcer Prevention Protocol.

References
Bryant R. Acute and Chronic Wounds. 2nd ed. St. Louis: Mosby; 2000.
Frantz RA. Evidence-based protocol: Prevention of pressure ulcers. Journal of Gerontological Nursing. 2004;30(2):4-11.
Hobbs BK. (2004). Reducing the incidence of pressure ulcers: Implementation of a turn-team nursing program. Journal of
Gerontological Nursing. 2004;30(11):46-51.
Makelbust J, Sieggreen M. Pressure Ulcers: Guidelines for Prevention and Management. 3rd ed. Pennsylvania:
Springhouse; 2001.
Wound, Ostomy and Continence Nurses Society. Guidelines for the Prevention and Management of Pressure Ulcers.
Glenview, Ill; 2003.
U.S. Department of Health and Human Services. Pressure ulcers in adults: Prediction and prevention clinical practice
guideline. 1992.

84 The OR Connection
Forms & Tools Policy Sample

Reprinted with permission.

86 The OR Connection
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Management/Employee Checklist Forms & Tools

Checklist: Organizational Assessment Questions Regarding


Management Commitment and Employee Involvement

 Is there demonstrated organizational concern for  Is there tracking, trending, and regular reporting on
employee emotional and physical safety and health violent incidents through the safety committee?
as well as that of the patients?
 Are front-line workers included as regular members
 Is there a written workplace violence prevention and participants in the safety committee as well as
program in your facility? violence tracking activities?

 Did front-line workers as well as management  Does the tracking and reporting capture all types of
participate in developing the plan? violence— fatalities, physical assaults, harassment,
aggressive behavior, threats, verbal abuse, and
 Is there someone clearly responsible for the violence sexual assaults?
prevention program to ensure that all managers,
supervisors, and employees understand  Does the tracking and reporting system use the latest
their obligations? categories of violence so data can be compared?

 Do those responsible have sufficient authority and  Have the high-risk locations or jobs with the greatest
resources to take all action necessary to ensure risk of violence as well as the processes and procedures
worker safety? that put employees at risk been identified?

 Does the violence prevention program address  Is there a root-cause analysis of the risk factors
the kinds of violent incidents that are occurring in associated with individual violent incidents so that
your facility? current response systems can be addressed and
hazards can be eliminated and corrected?
 Does the program provide for post-assault medical
treatment and psychological counseling for healthcare  Are employees consulted about what corrective
workers who experience or witness assaults or actions need to be taken for single incidents or
violence incidents? surveyed about violence concerns in general?

 Is there a system to notify employees promptly about  Is there follow-up of employees involved in or witnessing
specific workplace security hazards or threats that are violent incidents to assure that appropriate medical
made? Are employees aware of this system? treatment and counseling have been provided?

 Is there a system for employees to inform management  Has a process for reporting violent incidents within the
about workplace security hazards or threats without facility to the police or requesting police assistance
fear of reprisal? Are employees aware of this system? been established?

 Is there a system for employees to promptly report Source: U.S. Department of Labor. Guidelines for Preventing Work-
place Violence for Health Care & Social Service Workers. Available
violent incidents, "near misses," threats, and verbal at: http://www.osha.gov/Publications/OSHA3148/osha3148.html. Ac-
assaults without fear of reprisal? cessed June 19, 2008.

Aligning practice with policy to improve patient care 89


Forms & Tools Incident Report

Confidential Incident Report

To: ________________________________________ Date of Incident: _______________________________________

Location of Incident (Map/sketch on reverse side or attached): ______________________________________________

________________________________________________________________________________________________

From: _______________________ Phone: _______________________ Time of Incident: ________________________

Nature of the Incident ("X" all applicable boxes):

❑ Assaults or Violent Acts: ____ Type "l"____ Type "2"____ Type "3"____ Other____

❑ Preventative or Warning Report

❑ Bomb or Terrorist Type Threat ❑ Yes ❑ No

❑ Transportation Accident ❑ Contacts with Objects or Equipment

❑ Falls ❑ Exposures ❑ Fires or Explosions ❑ Other

Legal Counsel Advised of Incident? ❑ Yes ❑ No EAP Advised? ❑ Yes ❑ No

Warning or Preventative Measures? ❑ Yes ❑ No

Number of Persons Affected: ___________________________________________

(For each person, complete a report; however, to the extent facts are duplicative,
any person's report may incorporate another person's report.)

Name of Affected Person(s): __________________ Service Date: _____________

Position: ___________ Member of Labor Organization? ❑ Yes ❑

No Supervisor: __________________ Has Supervisor Been Notified? ❑ Yes ❑ No

Family: _____________________ Has Been Notified by: ? ❑ Yes ❑ No

Lost Work Time? ❑ Yes ❑ No Anticipated Return to Work: ____________________

Third parties or non-employee involvement (include contractor and lease employees, visitors, vendors, customers)? ❑ Yes ❑ No

Nature of the Incident


Briefly describe: (1) event(s); (2) witnesses with addresses and status included; (3) location details; (4) equipment/weapon
details; (5) weather; (6) other records of the incident (e.g., police report, recordings, videos); (7) the ability to observe and
reliability of witnesses; (8) were the parties possibly impaired because of illness, injury, drugs or alcohol? (were tests taken
to verify same?); (9) parties notified internally (employee relations, medical, legal, operations, etc.) and externally (police,
fire, ambulance, EAP, family, etc.).

Previous or Related Incidents of This Type? ❑ Yes ❑ No

Or by This Person? ❑ Yes ❑ No Preventative Steps? ❑ Yes ❑ No Source: U.S. Department of


Labor. Guidelines for Preventing
OSHA Log or Other OSHA Action Required? ❑ Yes ❑ No Workplace Violence for Health
Care & Social Service Workers.
Incident Response Team: ______________________________ Available at: http://www.osha.
gov/Publications/OSHA3148/osh
a3148.html. Accessed June 19,
Team Leader: __________________________________________ __________________ 2008.
Signature Date

90 The OR Connection
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